Monday, February 1, 2010

Competency and medical care

A radiologist in Saskatchewan is again in the news over the weekend for what is becoming a tired and frustratingly common reason: a question of past competence (Click here). We have seen this before in other medical specialties, for example the stories involving pathologists in both Newfoundland and Ontario in recent years.

I have a couple of comments about this:

First, there has been a tendency, particular with this case, to misdirect the conversation into one involving foreign trained doctors. I have had the opportunity to work with many foreign medical grads; the vast, vast majority are as well trained, caring and competent as any produced by Canadian medical schools. We shouldn't let closet racism enter the discussion here. We need to be able to deal with competency issues in physicians, and that's what this is. Full stop.

Second, the error rate from this particular radiologist has been reported in the CBC stories to be at about 2%, and some have asked whether it is fair to label someone who is 98% "right" as being incompetent. Just how significant is a 2% error rate anyway?

The real answer of course is that it depends upon both the nature of the error and the patient flow rate. For example, if a radiologist sees 50 radiographs per day (not unreasonable) a 2% error rate means that each day, one patient would be misdiagnosed.

However, not all errors are problematic. The radiologist might deliberately err on the side of caution, for example, and order extra "unnecessary" tests to be certain of the patient's condition. Also, there is no information to tell us what the baseline disagreement rate (the "inter-rater reliability") between radiologists in this population is. Is 2% high? Average? Or low?

On the other hand, if only one in ten of the errors have a risk of seriously harming a patient, then only 10 working days would be required to produce a clinical disaster. That's two patients a month, on average. Clearly, we need to know how often bad things happen, not what the rate of error is, in order to interpret this information.

The CBC article quotes the provincial college as stating that a worrisome number of Dr. Tsatsi's errors had the potential to do serious harm to patients. While that implies a degree of review, it doesn't leave the rest of us with much comfort regarding process. It would be far better (and somewhat braver) for the provincial college to quote relative risk in this case: that a patient reviewed by the doctor under investigation had, say, twice the risk, or four times the risk of harm than a patient whose x-ray was reviewed by another.

Questioning the competency of medical care is never wrong; individual physicians should be prepared to open up and declare their experience and comfort level in the management of any case. Having said that, inadequate reporting of these cases and poor presentation of the facts by the medical establishment just muddies the waters, adds to a sense of vague unease in the population, and ultimately serves no one. Give us the numbers, folks.

Tuesday, November 24, 2009

Practice Pandemic: What we have learned to date

Two weeks after my last post, and although the days are still busy, we are actually seeing patients in the Emergency Department who don’t have flu-like illness  (yay!).  Flu assessment clinics are starting to come down, and maybe the peak for this phase of the pandemic at least has past.  Time to reflect on what we did right and wrong, and maybe how to do better next time.

I can hear some of you sigh from here.  Next time?  Will the fear mongering never stop??

It isn’t fear mongering, though, to plan wisely for events like this in the future.  The story of new illness in the last half century has largely been that of infectious or infectious-like disease; Ebola, AIDS, Kawasaki’s, Lyme disease, West Nile, SARS, now new forms of pandemic influenza and many others.  The apocalyptic view of these is almost certainly an over-interpretation.  Nonetheless, we will probably see striking surges in patient flow in the future related to new emerging illness.  Not planning would be foolish.

There are lots of issues, and no doubt we will be hearing more about this in the months to come. For now, though, here are three of mine:

1)      Should we have done anything at all?

The cost isn’t in, but it will be high.  We purchased enough vaccine to immunize an entire nation, we spent money on pandemic planning at every level from individual businesses right up to the federal government.  We hired all those folks to staff the flu assessment centres and poured money into public service messages, communications and doctor “tool kits”.  All that for a virus that, for most, was only minimally worse than the usual seasonal flu.  Did we over-react?

The retrospectoscope, they say, has 20:20 vision.  There are two ways to look at this process.  Canada spends roughly $180 billion per year on health care;  in those terms pandemic costs will likely not be a high percentage of the overall budget.  Also from everyone’s perspective, politicians to nervous parents, it is far better to be safe than sorry.  This was a new virus, and in the spring, when decisions had to be made, the hazard associated with it was just not known.  We have a model, only a century ago, of a similar event that had substantial impact. 

Wise leaders don’t roll the dice with population health.  No, I don’t think we over reacted.

2)      Was the immunization campaign appropriate?

During the week that peak patient flow (to date) was recorded at the emergency department I work in, we had immunized only 20% of the population.  Six year olds with cystic fibrosis were still not on the list to be immunized, while healthy four year olds were lining up for hours.  Did this make sense?

There were certainly problems.  In the pandemic planning process, the assumption was that anti-vaccine hysteria would be a stronger force, that the population needed to be informed about the benefits of vaccination.  With the unfortunate deaths in Ontario of three children due to H1N1, that was just no longer true.  Parents wanted their kids protected, and right now.  Public health practitioners were left making decisions on the fly about whether it was best to try to nip the pandemic in the bud, by immunizing the pre-schoolers who are probably a big reservoir, versus focusing on those who had high risk characteristics. 

What could we have done better?  A clear strategy regarding the rationing of immunization and treatment, laid out not just for the health care workers but also for the public in the weeks leading up to the flu’s arrival would have been very helpful.  Most healthy adults were happy to step back and let others get to the front of the line first, I think.  Individuals who were at high risk for bad outcomes, not just for catching the flu, should have had their needs met, at the same time as front line providers and, say, hockey players.

3)      Were medical professionals prepared?

I think we were as ready as we could be.  The nitty gritty details over who to treat with Tamiflu, who to admit for observation, who to worry about were to some extent issues that we needed experience with the virus in order to assess.  Once it became clear that most children were not going to suddenly deteriorate, our emergency times improved and so did the confidence in our treatment decisions.

What would have helped?  We should have all been logged into one big chat room at the end of each shift, with less worry about privacy and confidentiality and more about sharing knowledge and experience.  I know that our group initiated an email discussion within a few days of the onslaught, and, I think, established a reasonably uniform approach for each practitioner.  But others, particularly those in isolated clinical settings, were not so lucky.  We had  a lot of phone calls from excellent family physicians asking just how we interpreted the various guidelines.  We live in a world of highly linked social networks; something like this for the H1N1 surge would have been very useful.

There are probably many other areas of potential improvement, these are just my thoughts.  Any comments?  What was your experience of H1N1 like?  Let us all know by clicking the comments bar below.

Friday, November 6, 2009

An excellent article ...............

One of the big problems with the internet is that ignorance and fear are given a platform that is just as large as knowledge and wisdom.  One of the big problems with celebrities is that they are tempted to speak without knowing what they are talking about.  Combine the two, and children and families can be injured.

Worth a look."

Wednesday, November 4, 2009

H1N1: Two weeks in, and what to expect now ...

It has been two tiring weeks for anyone involved in the public or acute care health systems, whether as workers, patients or family members.

Tonight on the radio, I heard an announcer discussing the possibility that the immunization program in Nova Scotia might start to slow down the rate of new cases.  I noticed that the spokesperson for public health was careful not to support this notion ... she correctly pointed out that, although the immune system starts to react almost immediately on contact by the vaccine, it generally takes two weeks for the shot to generate maximum benefit.  We have just begun the immunization campaign in Nova Scotia; according to the CBC, about 9% of the population has been immunized to date.

From a viral perspective, in other words, there is still a lot of food to eat on the table.

Australia has it's peak flu season in our summer, so they have already been through one H1N1 season.  According to their surveillance data,  the peak of the epidemic occurred 9 weeks after onset, and the incidence of new cases only fell to below the level seen at two weeks (where we are now) after 15 weeks.  That's nearly four months, for those of you with plans to hold off on that immunization.  A long, long time to hold your breath in public.

Canada will probably do better.  The H1N1 vaccine was not available in July, when Australia was facing its outbreak.  Australia has a high quality medical system; nonetheless, their intensive care units were stressed by the load of patients requiring ventilators.  While this is a very rare thing in children with this disease, and very uncommon even in adults, if 1/3 or 1/2 of your entire nation is sick with the flu, the numbers of "rare" things start to become significant.  There is every reason to believe that the vaccine will reduce the overall rate of disease, and therefore the stress on critical areas like ICU's and Emergency Departments.

All this depends, of course, on us getting enough individuals immunized in time.  The Harper government was on record last week that Canada will be amongst the first to offer full immunization to its citizens, and that the current timeline to complete that process is .... Christmas.  I don't want to criticize public health officials, who have been working flat out on this problem since the spring.  But we do have to recognize that Christmas is 9 weeks into our national pandemic ... or at about the same time the Australians experienced their peak.

Finally, H1N1 isn't the only kid on the block.  Beginning every year in late December and peaking in February, a bug called RSV comes to town.  If during those months you have a nasty, snotty nose and a bad cough, or your baby / toddler is wheezy and hot, odds are good that you have RSV.  As a westerner I have always thought of RSV as the cash crop of emergency pediatricians ... February is certainly the month you find us toiling in the fields.  It is usually the busiest month of the year, with the greatest number of hot, coughing  children.  Sound familiar?

So ... my forecast is for a pediatric heat wave, with associated hack, wheeze and a whole lot of snot right through until April.  Get out your wellies, folks...

Tuesday, November 3, 2009

Whoops ........ you ARE writing to me .....

Just finally realized that some of you were writing me back (sorry ... new to blogger ...).  So I have published all the comments and have started writing my responses.  Check below!


Wednesday, October 28, 2009

Pandemic Panic: How to sleep soundly this week.

The fear is certainly out there.

Last night the tide of scared parents was high and rising in the emergency department.  Our beds were full, several patients were at some risk from their illnesses, and all of us, the nurses, front staff and myself, were running hard. There is always the worry in a busy emergency department that information might slip through the cracks.  Experienced workers deal with that by knowing how to run and look at the same time, by keeping their sense of humor and supporting each other.  A cup of tea and a piece of toast can be pretty important gifts at 4:00 a.m.  It's always easier, I think, in children's units because, frankly, the kids are much more likely to smile back.

One common thread from last night that both heartened and dismayed me: the number of people apologizing for showing up.  A couple of children have died in Ontario this week from H1N1, and several parents said that once awakened, they just couldn't go back to sleep again.  "I know that I am being silly!"  One parent said.  "But if anything ever happened to her ..."  Her daughter, just pre-school, solemn, flushed and beautiful, blinked back and forth between us, not quite sure what the hell was going on.

So just so you know, folks, in case there was any doubt, I will let you in on a not-so-secret:

It's okay with us if you love your kids.  Really.

David Butler Jones, Canada's Grand Poobah of public health has been on the radio today saying that parents should avoid local emergency departments where possible.  We should be "reserving those resources" for children who are really sick, he says.  Now Dr. Butler Jones is a pretty smart guy, and I respect a lot of what he has done.  But his request is a bit difficult to actually implement, isn't it?  How are you, Ms. Accountant, or Mr. Business Man, or Ms. Mechanic, or Mr. Chef ... how are you supposed to know whether your kid is "really sick" or not?  Doesn't that take a bit of expertise in the first place?

In technical terms, what you are being asked to do is parent triage.  Without any training, and with often conflicting ideas as to what constitutes "sick", we (the Canadian health care industry) are asking you to essentially bet your child on your competence with a new and highly hyped viral illness.

To do this we give you telephone help lines that have been shown to actually increase visits to emergency departments time and time again (if you have ever watched "The Emperor's New Groove" this is a "Why do we even HAVE that lever!?" moment -- If you haven't seen it, makes a great "sick kid" movie).  In any case, those lines have long, long waiting times, and the people giving you advice?  They don't get much feedback.  We don't call them up from the ED and say "Frank!  Good call!  Glad you asked that child to come in!  Keep up the good work!"  Nope.  These poor folks are stuck, not seeing your child, working from decision trees that minimize legal liability and maximize efficiency.  Nearly an impossible task ... when I criticize outcomes, it isn't the nurses on the end of those lines that I am complaining about.

Here, then, is another not-so-secret to share with you ....  At three a.m., even if you manage to get through to the help line, you are the one that has to look at your child and interpret the degree of illness you see.  You are on your own in that bedroom with that hot kid.  You have to make up your own mind what to do.

So how do you do this?

First: is your child high risk?  Chronic illness like moderate to severe asthma, other lung, kidney, nervous system diseases and illnesses that affect immunity like cancer are all linked to higher risk.  Don't think.  Be seen.

Also linked to higher risk is pregnancy, but the issue here is getting seen and possibly treated for H1N1 ... usually best to call your family doctor and schedule that.  However, if your pregnant adolescent looks sick (see below) you might consider an emergency visit.

Age is another risk.  Basically, under two years the younger your child the higher the theoretical risks.

All children under three months should be seen without question and immediately if they have a fever or other symptoms of H1N1.  Don't think about this ... just come in.  This is a good use of emergency department resources.

Most of us would want babies between 3 and 6 months seen within promptly (i.e. today), immediately if they look significantly unwell (again, see below).  Above 6 months?  Depends on who you ask.  If your child is less than 2 years old, my personal advice would be to be seen by your family doctor with any symptoms, and to come into the ED if your child's degree of illness makes you too nervous.

How should you decide how nervous to be?   Try not to judge your child by any numbers.  I don't really care how high the fever is, or how many bouts of diarrhea or vomiting there have been ... these are distractions for most parents, not true grist for the decision making mill.  A more important measure is to stop, step back, and look at the whole kid.

What is your child's attitude like?  Is your kid crabby, whiny, upset, fatigued?  Is your child breathing hard (fast, with increased effort, as if she has just run a race)?  If any of these are true, and if treating with acetaminophen or ibuprofen doesn't make your child almost normal, a visit to the emergency department should be considered.

A word about that choice:  I prefer ibuprofen but there is controversy about this.  Acetaminophen (Tylenol, Tempra, others) has been used for about 10 to 15 years longer than ibuprofen in kids, so there is a longer record of use, and we (the medical profession) know it better.  Acetaminophen is very safe; the problem is it just isn't as effective against pain as ibuprofen.  For younger kids, who can't verbalize their discomfort well, ibuprofen (Motrin, Advil) is an excellent pain killer.  I use it in otherwise healthy children over 10 months of age who are not significantly dehydrated, with no allergies or other specific medical conditions (e.g. kidney disease).

An hour after giving something for the fever and pain, your kid should look pretty good, almost normal.  The fever may be up, but that's just a number, and I would ignore it.  More importantly, judge the parameter that you are an expert in .... what is your child's attitude like?

If your child is now happy, playful, exploratory, DRINKING, essentially normal in attitude, and your child is not breathing particularly fast or hard, it is reasonable to consider staying at home.  Your own level of anxiety should determine what you do next ... never let a blog tell you what to do!  But if your heart tells you that your child is settling and not in danger, and your child's response to anti-fever and anti-pain medication also seems to point that way, you can trust yourself.  If you need further advice, you can try the help lines, or better try your family doctor's office to speak to the on-call physician.  Or, if things don't look right, you can come in to the emergency.

Critically, two points:

1) Reassess, reassess .... if you are reassured now, take another look in an hour or two, and again frequently throughout the day.  Your measure as to whether your child is getting worse or better will be more accurate the more often you look.  If the trend is stable, or improving, great.  If your child seems to be getting less bang from the ibuprofen or acetaminophen, or if there are other issues that worry you, call your family doctor.  If things are really concerning, come to emergency.

2) Always listen to yourself.  In particular, don't let my words or any other online resource make you feel guilty about seeking care if you are worried.  If you are still concerned, if you are going to be up watching your child sleep, for example, or if you just can't quiet that nagging voice that says he might be sicker than you think .... well come on in and wait with the rest of them :).  There really is only so much you can do at home.

There is more on this on my website (sorry about some broken links ... these are being fixed as fast as I can):

and especially at:

Let me know what you think!  Click on the "comments" link immediately below this post.


Tuesday, October 27, 2009

Taming the Hog: Immunization or Not for "Swine Flu"

This week many people have asked me what my advice is regarding immunization for H1N1 flu. I thought it was probably easiest to just put this up on the blog, and let the conversation go where it wanted. So here is my view of things.

First, H1N1 is not a "killer flu" for the vast majority of patients who come down with it. However, it is a royal pain in the butt, carrying a great risk of missing work, sleepless nights, and attendant worry about your health or the health of your children.

H1N1 has increased risk for some demographics, most notably pregnant women and asthmatics. That doesn't mean that the risk is high, just higher. For some people, particularly those with significant lung, heart or immunity issues, any influenza can be downright dangerous, and H1N1 is no different.

On the other hand, the H1N1 vaccine is just another flu shot. There isn't anything particularly new about it ... except that it carries cut up and inactive parts of H1N1 flu instead of other types of influenza. The other (non-viral) components are frankly very similar or identical to vaccines that we have used before. Like other flu vaccines, it is grown on chicken eggs, so those individuals with egg allergy should probably discuss its use with their physician. But, otherwise, it is almost certainly a safe tool to help prevent infection.

People often get bent out of shape by the fact that injecting virus fragments into your arm doesn't seem quite .......... natural. To my mind this is fuzzy thinking. When your body encounters a live influenza virus, your immune system does all that it can to destroy the invader, which basically means chopping it up into components and then destroying those. When all the viral agents are disposed of, and the body's system is tuned to fight any new ones it encounters, the illness ends.

The difference, of course, is that the live virus has a window of opportunity in the healthy host to replicate (causing the fever, headache, sore throat and cough) and then to move on. The symptoms from the vaccine, on the other hand, include a sore arm, maybe mild muscle aches for a day or two. I have had the flu, and I have been vaccinated .... getting shot is better.

What about those individuals who "always get sick when they get a flu shot"? Well, most of those folks are getting their shots during flu season. They almost certainly are not getting sick from the shot, but because they are one of the up to 75% of the population that gets the flu each year, and the immunization hasn't had time to work yet.

Finally, what about those who are healthy, and "never get the flu anyway"? Well, as I said above, H1N1 is not a terrible disease for most, and for some it actually has quite mild symptoms. Some, undoubtedly, don't have the fever, or much of a cough or sore throat. So these individuals don't stay at home. So they can brush up against the pregnant woman, or the guy with leukemia at the bus stop, and pass the virus along. In that context, it seems to me, the responsible thing to do is to go get shot, so that you aren't a reservoir for others in your community.

Bottom line:

1) The disease isn't terrible, don't panic. But it is at least a big pain and, for some vulnerable people, maybe a lot more than that. Many un-immunized people will be missing work, school and sleep because of this virus.

2) The vaccine is not some scary, rushed process, but rather an example of tried and true techniques applied to a new virus. This is intelligent, competent medicine that will almost certainly reduce the risk of infection, not a FrankenShot here just in time for Halloween.

3) My advice: unless you have severe allergies,go get shot! And shoot everyone in your family too.

Click on the "comments" link immediately below this link to let me know what you think about this ...