Ethics of fighting Ebola

I can't think of too many people better qualified to break down the ethics of fighting Ebola than Peter Singer.

In this respect, Ebola is – or, rather, was – an example of what is sometimes referred to as the 90/10 rule: 90% of medical research is directed toward illnesses that comprise only 10% of the global burden of disease. The world has known about the deadly nature of the Ebola virus since 1976; but, because its victims were poor, pharmaceutical companies had no incentive to develop a vaccine. Indeed, pharmaceutical companies could expect to earn more from a cure for male baldness.

Government research funds in affluent countries are also disproportionately targeted toward the diseases that kill these countries’ citizens, rather than toward diseases like malaria and diarrhea that are responsible for much greater loss of life.

The most accurate way to judge the efficacy of a vaccine is through a double blind trial. One group of patients suffering from the malady are given the potential vaccine, the other set a placebo, and neither the doctors nor patients know who received what. When dealing with a shortage of vaccines and a disease as deadly as Ebola, the usual rules may not apply. That may be okay.

But, when facing a disease that kills up to 70% of those who are infected, and no accepted treatment yet exists, patients could reasonably refuse consent to a trial in which they might receive a placebo, rather than an experimental treatment that offers some hope of recovery. In such cases, it might be more ethical to monitor carefully the outcomes of different treatment centers now, before experimental treatments become available, and then compare these outcomes with those achieved by the same centers after experimental treatments are introduced. Unlike in a randomized trial, no one would receive a placebo, and it should still be possible to detect which treatments are effective.

The presumption of human error

Naturally, we respect and admire doctors. We believe that health care is scientific. We think of hospitals as places of safety. For all these reasons, it comes as something of a shock to realise that errors still play such a significant role in whether we leave a hospital better or worse, alive or dead.

The National Audit Office estimates that there may be 34,000 deaths annually as a result of patient safety incidents. When he was medical director, Liam Donaldson warned that the chances of dying as a result of a clinical error in hospital are 33,000 times higher than dying in an air crash. This isn’t a problem peculiar to our health-care system. In the United States, errors are estimated to be the third most common cause of deaths in health care, after cancer and heart disease. Globally, there is a one-in-ten chance that, owing to preventable mistakes or oversights, a patient will leave a hospital in a worse state than when she entered it.

There are other industries where mistakes carry grave consequences, but the mistakes of doctors carry a particular moral charge because their job is to make us better, and we place infinite trust in the expectation they
will do so. When you think about it, it’s extraordinary we’re prepared to give a virtual stranger permission to cut us open with a knife and rearrange our insides as we sleep.

Perhaps because of the almost superstitious faith we need to place in surgeons, we hate to think of them as fallible; to think that they perform worse when they are tired, or that some are much better at the job than others, or that hands can slip because of nerves, or that bad decisions get taken because of overconfidence, or stress, or poor communication. But all of these things happen, because doctors are human.
 

What the medical profession can learn from the airline industry about how to protect against human error. A riveting story about how we must build around the assumption of inevitable human error.

The passage above mirrors my own journey towards realizing that not all doctors are infallible. It may seem silly now, but as a child, I had a learned reverence of the medical profession. All the training, all the accreditation, the requirement to address them by a title all their own—“Doctor”—was blinding.

In 1997 I was back in the Bay Area and went to play pickup basketball with some old Stanford classmates at a local gym. A scrimmage game against a group of older Greeks turned heated, as such games are wont to be with the physical release of so much pent up testosterone. On one drive to the basket, I took a hard shove and went flying sideways. I landed on my left food and my left knee flew sideways an opponent's leg that was planted on the ground.

I felt a searing pain immediately and collapsed. Some teammates carried me to the sideline, and my knee immediately started swelling. I'd never felt anything like this before. Something had happened, but I didn't know what.

I crutched my way back to Seattle, stayed on crutches for a few days, and eventually got in to see an ortho. He laid me down, tugged on my leg a bit this way and that, moved my leg around, and gave me a comforting diagnosis. It was a mild sprain, I could resume light physical activity after the swelling subsided.

At the gym, on an elliptical trainer, something didn't feel right. But the doctor had done some tests, who was I to question him? The web existed, but it was much sparser than it is now. WebMD and sites like that didn't exist.

Back then, Amazon's unofficial official company sport was broomball. The popular stereotypes of technology companies being populated with a bunch of meek, gaunt, sun-deprived software developers neglect the army of MBA's with their world-conquering ambitions, the ex college jocks in business development, the crazy endurance athletes whose motor played on the field or in the office. We played at company functions, and the games felt like some form of trial by combat.

My knee still felt off, but I wasn't about to miss out on our team's broomball contest. We played on a muddy field, it was like some form of field hockey minus pads. You just had to accept that you'd leave battered, your shins a mess of bruises. We taped tennis balls to the ends of our broomsticks so as not to take out anyone's eyes.

From the start I couldn't move that well, so I hung back to play defense. And then an opponent broke loose, a herd of people chasing him, and I moved to intercept the ball. At best, with all the momentum he'd built up, I hoped to deflect the ball horizontally to give the rest of my team a chance to catch up and reset.

As I moved diagonally to meet the path of the ball, he tried to make a sharp cut, but on the muddy field, he couldn't turn enough, and both ball and opponent came sideways and collided with me.

My left leg experienced what the doctor would later call a pivot shift, where the top and lower leg came out of alignment. I fell to the ground screaming. My day was over, and I don't remember now how I drove myself home considering it was a manual transmission.

I found myself back in that same ortho's office a day later, and I told him something wasn't right, to check me again. This time, he consented to perform an MRI.

When the results came back, he was almost sheepish in sharing the news. Though he'd performed the standard Lachman Test and some other tests the last time I'd come in, in fact I did have a torn ACL. I'd been running around for weeks without my left ACL.

Needless to say, I didn't let that ortho perform my ACL reconstruction.

The first time I visited, was the ortho hesitant to order an MRI because of the expense, because I was on an HMO? Or did he just not perform the Lachman test properly? It still haunts me, but the lasting consequence was the shattering of my belief in the infallibility of doctors. I still have deep respect for the medical profession, my brother and his wife are both doctors whom I turn to again and again for advice, but nothing about medical training magically removes human error from day to day life.

 

If the severity of Elaine’s condition in those crucial minutes wasn’t registered by the doctors, it was noticed by others in the room. The nurses saw Elaine’s erratic breathing; the blueness of her face; the swings in her blood pressure; the lowness of her oxygen levels and the convulsions of her body. They later said that they had been surprised when the doctors didn’t attempt to gain access to the trachea, but felt unable to broach the subject. Not directly, anyway: one nurse located a tracheotomy set and presented it to the doctors, who didn’t even acknowledge her. Another nurse phoned the intensive-care unit and told them to prepare a bed immediately. When she informed the doctors of her action they looked at her, she said later, as if she was overreacting.

Reading this, you may be incredulous and angry that the doctors could have been so stupid, or so careless. But when the person closest to this event, Martin Bromiley, read Harmer’s report, he responded very differently. His main sensation wasn’t shock, or fury. It was recognition.
 

RELATED: Atul Gawande's great book A Checklist Manifesto.

This May Hurt a Bit

Did you know that many surgeons play music during operations? It was going so smoothly that we were humming along to “Who Says You Can’t Go Home?” It was during the bridge of the song that your blood pressure suddenly dropped. The anesthesiologist called it out. I looked at the monitor and saw numbers flashing in red.

There was a lot of red, actually. Blood in the wound, blood in the suction container, blood in transfusion bags, bloody footprints on the floor. No more than with any other patient. But I think somewhere along the way I learned to take the sight of liters of blood for granted.

I was scared. I stopped watching them stitch and stared at the monitor, which suddenly seemed like my closest connection to you. They called out the medications they were giving you to raise your blood pressure.

After a few minutes, it worked. Your blood pressure slowly climbed to green numbers. I was still shaking as I silently willed the numbers to stop bouncing around.

But the numbers stubbornly drifted down. Even though they were keeping up with the fluids. Even though you were on medications that force your blood vessels to clamp down and your heart to beat harder.

The red returned and was unrelenting. Your blood pressure was too low, your heart rate too high, the tracing of your heart rhythm irregular and non-shockable.

“We can be done in ten minutes,” the surgeons said.

I’ve never seen surgeons work so fast. They’re usually so particular about their stitches, getting the perfect angle and length for each one.

I’ve also never seen so many anesthesiologists at the head of an operating table.

I’ve never seen an ICU bed booked so quickly.

I’ve never seen someone lose their carotid pulse.
 

From Shara Yurkiewicz, a fourth-year student at Harvard Medical School, at her blog This May Hurt a Bit at Scientific American.

King Richard III's Genome to be Sequenced

The process could reveal his hair and eye colour, his susceptibility to conditions including Alzheimer's disease and diabetes, whether he was lactose intolerant, and whether the scoliosis that contorted his spine was genetic. It could also show if any of the surviving portraits, all completed years after his death, are accurate.
 

The article says Richard III will be the first famous historical figure to have his genome sequenced, but everyone knows that the actual first was Tupac so they could bring him back at Coachella that one year.

I know for one that I can't wait to find out if Richard III was lactose intolerant. Will we be able to tell if he smelled asparagus in his pee, too? Entire history books await rewriting.

New knee ligament

Doctors have discovered a new knee ligament, the anterolateral ligament. It doesn't seem possible that with years of medical research and millions of cadavers studied and knee surgeries performed that it would be possible to discover a new knee ligament, but there you go.

Whether a similar process occurs in living people who injure and don’t treat an A.L.L. — because they don’t know they have one — is unknown, Dr. Claes said, but is potentially the weightiest question raised by this new research. “We think that it’s quite likely many people who tear an A.C.L. also tear an A.L.L,” he said, and that lingering injury or weakness in this overlooked ligament could leave joints unstable.

But at the moment, that possibility is speculative, although Dr. Claes said that he and his colleagues had re-examined scans of some of the knees that they had operated on to repair A.C.L. injuries and identified concomitant A.L.L. tears in many of them.

He and his colleagues have begun planning and practicing surgical procedures for treating A.L.L. tears, but at the moment, so much remains unknown about the ligament, including whether it can heal without surgery.

I tore my ACL, MCL, and meniscus in one basketball incident, and now I'm wondering if I still have an ALL or if it's just dangling there. Someone should make sure Derrick Rose's ALL is in good shape.

Unintended consequences

In 2003, fearing that overworked medical residents were committing errors due to fatigue, the Accreditation Council for Graduate Medical Education put limits on how many consecutive hours residents could work on a shift.

Now, ten years later, it's not clear the change has had the desired effect. 

One study, led by Sanjay Desai at Johns Hopkins, randomly assigned first-year residents to either a 2003- or 2011-compliant schedule. While those in the 2011 group slept more, they experienced a marked increase in handoffs, and were less satisfied with their education. Equally worrisome, both trainees and nurses perceived a decrease in the quality of care—to such an extent that one of the 2011-compliant schedules was terminated early because of concerns that patient safety was compromised. And another study, comparing first-year residents before and after the 2011 changes, found a statistically significant increase in self-reported medical error.

While these studies suggest the complex nature of patient safety—that manipulating one variable, like hours worked, inevitably affects another, like the number of handoffs—there is another tradeoff, more philosophical than quantifiable. It has less to do with the variables within the system and how we tinker with them, and more to do with what we overlook as we focus relentlessly on what we can count.

Caveat: this essay by Lisa Rosenbaum in the New Yorker is a bit short on data for my liking, the above study feeling like just one insufficient data point. 

But the meta point about unintended consequences and complexity is worth noting. The increase in handoffs of patients, the decrease in time any one doctor spends with a patient, these all have consequences that work against the quality of healthcare, even as I believe more well-rested residents are a good thing, many of my doctor friends having been put through grueling rotations.

Alan published in NEJM

My brother Alan had an article published in the February 14th issue of The New England Journal of Medicine. We're all proud of him.

The article title: Selumetinib-Enhanced Radioiodine Uptake in Advanced Thyroid Cancer. As with all brilliant ideas, the conclusion of the article seem self-evident upon further reflection, I mean clearly you'd anticipate selumetinib producing clinically meaningful increases in iodine uptake and retention in a subgroup of patients with thyroid cancer that is refractory to radioiodine, it's amazing we never believed this before, ahhh, I have no idea what I'm talking about, why am I not smart enough, my life has no meaning.