AMEN BROTHER! Thanksgiving night I did 4 appys in a row. The first was perforated and had CHF, COPD, hypertension and an overall bad heart. The second was a healthy 25 year old (yay). The third was an obese 40 yo woman. The 4th was a 27 year old with advanced, untreated HIV disease with a high viral load. Try putting these people on a "care map." Hah. As a pilot the first thing that you're taught to do is pre-flight the plane to make sure it's fit for flight and to cancel if not. Sadly only one of the 4 patients was a good candidate for the OR. Does that mean I don't have to operate? No. Do these type of patients go against me in the "pay for performance" scheme? Who knows? Can I walk away from the patient b/c of the above. No.
Entertaining,funny as so much right on the mark.We don't make widgets or fly planes.I am going to have to tell my 3 or 4 regular readers about that entry.
Right on. Absent monitors on every case of every surgeon (and absent god-like qualities of those monitors) the idea of meaningfully evaluating surgeons is pretty elusive, even if it's desirable.
I have sat through a couple of presentations from my malpractice insurer given by some pilots now in the business of bringing medicine up to the safety level of flying.
Recently, anesthesiologists have also been touted a fine examples to all the rest of us to show how to reduce risk to the patient and of malpractice.
What both these groups have in common is a relatively discrete interval of risk, and a relatively short list of risks, along with a very tight control over the events happening during that interval.
But surgery and medicine as a whole do not have such sharp on and off points, don't have a list of things that can happen, and therefore anything not on that list is not OUR complication. Medicine ends up more like someone who might arrive safely home on a flight, then has an MI walking in the front door of his home and blames it on the pilot.
I also have been amused by exhortations from so-called experts who believe that medicine could be improved if we adopted the aviation model. There are some similarities. Like aircraft, patients are maintained by highly skilled personnel; the physicians who do this work have far more training than the mechanics employed by the airlines. A senior aircraft mechanic has the authority to pull an aircraft out of service if he does not believe it can be safely flown. A physician may accurately believe that a patient is on his last legs, but will do his utmost to keep the patient in service, knowing that any given sortie may be the patient's last. My surgical record would be much improved if my internist colleagues would only pull some of their rickety patients out of service, rather than sending them out into the world, to end up in my ER with an acute surgical illness. I also would have a better record if I, as the “pilot,” had the authority to declare that this patient is just not safe to fly, and that rather than going to the OR, he should be sent to the ultimate runway in Arizona where aged aircraft are sent. While only a tiny minority of aircraft will ever crash, it is an unfortunate fact of life that every patient will ultimately die. Sometimes those deaths occur after, and even as a result of, medical or surgical interventions. We could make our numbers a whole lot better if we as physicians decided to be more selective about which aircraft we choose to fly.
Of course, there's one other huge difference between medicine and the airline industry --- you can't get on a plane without purchasing a ticket, in advance, at whatever the posted rate happens to be at the time.
I used to think that a major difference between flying and receiving medical/surgical treatment is that if the pilot makes a serious error, wherever you go he goes along. Good incentive program.
I used to think that in the case of medical error only the patient suffered harm if a serious error was made.
Medical blogs have helped me better understand that in most cases, the physician suffers right along with the patient if a serious adverse outcome occurs due to a medical error.
There is one area however, that I think medicine can take a page from the aviation safety manual. What can be made more standard should be.
If you perform surgery in Hospital A in the morning and in Ambulatory Surgery Center B in the afternoon, what items can be made more uniform? Tray set-up, crash cart design, color coding on oxygen valves? And what group is influential enough to help design those kinds of changes for the industry?
I think it would be more fair to make the comparison to an aircraft mechanic.
An aircraft mechanic can also be coping with a 737 first thing, then switching to an aging 747, then repairing a Sopwith Camel.
And there are some more analogies - an aircraft mechanic needs to use the right equipment on every plane even if each plane make has different sized bolts. Systems used for doing this could also be applied to making sure each patient gets the medicine their doctor prescribed each time they need it.
Another constant across patients is that you don't want to leave things like sponges behind in patients. Standardised procedures for keeping track of operative equipment are important.
Regardless of your patient's starting condition, it's unlikely to be improved by a hospital-contacted infection. So good infection control procedures are important. And I can't see how those would vary from patient to patient (except to be more thorough for those patients with already-compromised immune systems).
My brother was in hospital after a bad accident - he spent a week in intensive care, another month in the neurology ward, and then was transferred to a hospital closer to my parents' home. I think the first hospital at least needed far better procedures for transferring notes about a patient. I do not expect any doctor to remain on duty for a week, let alone a month, but I was rather worried that us family were the main source of information between different departments and hospitals. That's another thing I think could be systematically improved.
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