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Risks in Medicine Part 1

Updated: Jul 4, 2020


I’ve written previously about the unaccounted harm that exists in medicine. I would argue that few certainties exist in medicine, similar to life. Some believe that the events in their life are inevitable. “It is what it is,” or “It was destined to be,” is a common explanation for love, careers, tragedy and so on. This heuristic may exist to preserve your brainpower to focus on survival instead of expected or lost potential. Which would be exhausting if one had to spend their day transfixed on the topic of possibility. A better way to state that would be that it is easy to believe reality is inevitable because it is the only reality you know. Actually, life is an infinite amount of potential outcomes, and the probability of those outcomes changes when new information becomes available.

To illustrate this in medicine I would like to tell a story. The details of the story have been changed for privacy purposes, but the principles are the same.

Event 1-The Advertisement: A (not quite elderly) woman listening to the radio on her drive home from work one day hears an advertisement from a local health system for a heart-smart CT scan. For $45 she could have the CT scan performed and provided information on her risk for heart disease. The women’s father died of a heart attack recently.

(A heart-smart CT scan is a scan of the heart that can view calcium deposits in coronary arteries. The degree of calcium is determined by a software program, then confirmed by a radiologist. The patient is assigned an Agastron calcium score. Based on this score the patient is placed in a risk quartile. Higher risk patients are offered consultation with a cardiologist to discuss heart disease.)

Event 2- The Test: Her anxiety about her health has increased since her father’s death. Even though she has no symptoms she decides to go ahead and pay the $45. She receives a phone call a few days later. It is a nurse form a cardiology office. Her scan showed she is in the high risk quartile, specifically there are calcium deposits in the main artery supplying her heart muscle known as the left anterior descending artery (LAD). She is offered a consultation with a cardiologist.

Event 3 – The Consultation: The cardiologist reviews the heart-smart scan. A thorough interview of the patient’s history and current symptoms is conducted. She does not have classic angina symptoms, but does state she has been “more tired” lately and can’t do what she used to do. This is difficult for the cardiologist because symptoms of heart disease can be subtle. Knowing she has the calcium in her arteries stress testing is passed over and an angiogram is recommended (cardiac catheterization).

At this point she is thinking this is pretty serious. She decides to go through with the test.

Event 4 – The Angiogram - Angiograms are common procedures for cardiologists. Most cardiologists will perform thousands of these throughout their career. This one would be considered routine. Cardiologist will use catheters to operate instruments inside the arteries of the heart to open areas of impeded blood flow from atherosclerotic plaques. As the catheter was traversing one of these plaques in the patient’s LAD something caused a significant impedance of blood flow. A dissection of the artery occurred. This happens when the inner layer of the vessel wall tears and blood flows into the vessel wall and eventually forms a large clot. This is truly a six sigma event for these unfortunate parties. Efforts to repair the dissection were unsuccessful. Without blood flow, the patients cardiac function quickly deteriorated. Within a few minutes she was in cariogenic shock. The cardiologist placed an aortic balloon pump and called a cardiovascular surgeon for emergent arterial bypass.

Event 5 - The Bypass - After consent was obtained from her frazzled family members the patient was rushed for coronary artery bypass grafting (CABG). Her sternum was opened. Her major blood vessels were clamped. Blood was diverted using large catheters to a bypass machine. Her heart was stopped. An artery from inside her chest called the mammary artery was harvested and attached to her LAD beyond the area of occlusion. Blood flow was restored (no simple feat). Her heart was restarted. She was sewed up and transferred to the ICU.

Event 6 - The ICU - Even though the bypass was successful her heart muscle remained significantly weakened. She could not breath on her own and required a ventilator. Her kidney function was significantly impaired due to the shock. She was suffering from pulmonary edema and a severe acidosis from her shock as well. Despite aggressive interventions her organ function continued to deteriorate. Her kidney function deteriorated further requiring dialysis to temporarily replace them. Her pulmonary edema was difficult to treat requiring her to remain on the ventilator. Her family members were told she may die. With the effort from several specialized doctors navigating a treacherous clinical course she improved. She was able to come off the ventilator after 7 days. Eventually her kidney function recovered and she was able to stop dialysis after 10 days. In total she spent 12 days in the ICU. She lived.

Event 7 - Discharge Day - After 18 days in the hospital she was discharged home. She had an opportunity to meet with each of her doctors on the day of discharge. She thanked each one of them for their effort to save her life. There were many handshakes, a few hugs, and lots of tears. She made an extra effort to notify the director the ICU how thankful she was for saving her life and she will always get her care at this hospital.

Event 8 - The Bill - A month later she was still recovering from her hospital stay. She required several services and her daughter moved in with her for a couple of weeks due to her debility. She receives a bill from the hospital. She had $3000 remaining to meet her deductible this year. She withdraws some money from her IRA, accepting the tax penalty, and happily writes a check to the health system. Her employee insurance plan picks up the rest.

I can’t help but wonder…what if she was making a left hand turn through a busy intersection during that commercial? People rarely pay attention to driving when driving. It seems unusual but we are all guilty of this. Driving doesn’t need our undivided attention most of the time. One exception is making a left hand turn in busy traffic. It’s difficult to listen to the radio when your life may be in jeopardy if you don’t pay attention. You should try doing both sometime. What if she was fantasizing about telling off her boss for her mistreatment that day? What if she decided to listen to the country station instead of local news?

How would her life be different today? This was not the most likely reality when the commercial reached her radio antenna. But what was?

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