Blindspots and Reflections in Acute Medicine

20130901-172904.jpgHave you ever pulled out into the fast lane and narrowly missed a car coming from behind you? You think to yourself ‘How on earth did I not see that car?’. We all know that this wouldn’t happen if we always checked properly before we pulled out, but few of us can pay full attention all of the time. After decades of many such needless accidents (estimated 800,000 per year in the US), car manufacturers finally introduced the convex wing mirror. This may not have been the most exciting innovation, but it works and saves lives. This reminds me of some of the avoidable problems with medical errors. It is surely about time that we recognised common ‘blindspots‘ and did something to improve patient safety. If these situations are predictable, we should be discussing these issues frankly with each other and especially with our trainees. When we teach our students we need to admit that we have personally made mistakes, but show them how we are learning from them so that patients can be protected from these errors in the future.

Have you ever reflected on a acute medical ward round and realised that you have missed something that should have been obvious to you? After passing the ‘milestone’ of 20 years as a consultant physician I can see some recurring themes. You might think that we should have learnt from our mistakes, but some things seem to happen again and again. And when we get older we need to be even more aware of our limitations because other staff may not have the confidence to point out our mistakes.

A Typical ‘Blindspot’ in Medicine: The ‘alcoholic’
We call it the ‘revolving door’ syndrome. These patients often come in to hospital intoxicated with alcohol levels that would put the rest of us in intensive care or worse. After a day or two of confusion and aggression the medication helps them settle with and they leave, promising never to drink again. Sadly, many walk straight to the local off license and the whole process starts again. Eventually the well of empathy can run dry. Medical and nursing staff can be just a little less attentive, and this can lead them to make serious errors they would normally never make.

Here are a couple of stories that I hope will help to illustrate how this can happen.

A man came in to a hospital agitated and confused with a very high alcohol level. He was an alcoholic who had been in many times before in a similar state. He usually woke up after a day or two and went through the detox process. The examination in the ED was a brief one, if the notes were anything to go by. On that occasion his confusion didn’t settle and he deteriorated. A CT scan was ordered – belatedly – and it turned out that he had an undiagnosed skull fracture with multiple contusions in his brain. If it wasn’t for the alcohol the scan would have been done on arrival into the ED. Head injury guidelines have since helped to make this sort of error less likely to happen, but sadly it is not an exceptional case.

Another man with chronic alcohol problems came in to a hospital in a similar intoxicated state. On recovery a couple of days later he complained of a pain in his shoulder. He had thrown things at the nursing staff the night before and there wasn’t a lot of sympathy around. After a brief examination his shoulder was X-rayed and to nobody’s surprise no fracture was seen. He was sent home. He was readmitted two days later and a fractured cervical spine was diagnosed. Would the assessment have been any more careful if he had not been an alcoholic? I am sure it would have been.

These stories are not particularly newsworthy and I’m sure you could easily have come up with similar reports. Judging from the headlines in the press, these incidents are not unique to the hospitals I have worked in.

There are a few lessons I am trying hard to put into practice:

  • Alcohol is a powerful analgesic, and serious injuries can easily be missed when an intoxicated patient is admitted.
  • Taking a clear history & performing a careful examination is often difficult or impossible when your patient is drowsy, confused or otherwise unco-operative. So don’t just rely on first impressions. Go back and re-examine. If in doubt, do the imaging.
  • Make sure that there is a good protocol in place for managing alcohol withdrawal including the use of scoring systems such as CIWA-Ar. This will help to prevent periods of agitation, confusion or drowsiness.
  • Set the example by always treating the alcoholic with respect, even if you are getting abuse.

Motor Vehicle Accidents can also be prevented by paying attention to the rear-view mirror: if you see a high powered motorbike approaching you might know from experience that it is likely to overtake you rather sooner than expected. An important skill in medicine is to develop the habit of honest reflection.