August 5, 2012
Unfortunately, the case of Sabrina Seelig at a Brooklyn hospital is not an anomaly. Medical errors that result in death are common in American hospitals. Only a few of these – the signature cases – have changed the fundamental ways hospitals do business. A few of these cases of “adverse events” or “failure to rescue” are iconic in the medical patient safety movement throughout the United States.
Dana Farber Cancer Center had the Betsy Lehman case. A health columnist for the Boston Globe died from a chemotherapy overdose for breast cancer in 1994. Josie King died of dehydration at Johns Hopkins in 2001. The 1984 Libby Zion case at New York Hospital led to a twenty-five year effort to change the national work hour rules for doctors in training. These cases all involved young women who died while under the protective care of their physicians. These are the “Ur” teaching cases in the patient safety movement in this country, the ultimate “opportunities” for improvement. They changed the way business is done in their hospitals and galvanized a movement beyond Boston, Baltimore and New York City.
From Libby Zion we learned that fatigue affects the judgment of physicians. We are not cyborgs with boundless energy who unstintingly deliver high quality care regardless of the hours we put in. From Betsy Lehman medication errors can be lethal from dozens of different pathways even in the most resourced hospitals with unlimited talent. Josie King taught us to listen deeply to our patients and their families. Their distress signals are not vacuous and without important medical meaning.
Ms. Seelig’s case brought us back to the fundamental’s of medical care. As we are more seduced by technology and dependent on specialists and computer printouts from imaging and laboratories, we sometimes fail to examine and re-examine the patient. It’s that basic.
We learned this way back. As residents in training at the Kings County Hospital Emergency Room, we faced a sprawling complex that was always packed to overflowing. We senior residents managed to establish a veneer of control by the art and rules of triage. Working closely with a couple of nurses and medical students we were the one eyed in the kingdom of the blind. Gun shot wounds and stabbings went to the trauma slot. Minor sprains and upper respiratory complaints got an automatic blood test or x-ray to minimize delays and create some space in the boxlike “Male” room.
The cases that caused the most distress and anxiety from the lore of previous residents were handed down to the next generation of trainees. Mental status changes were high on the list of tricky and dangerous among the banal and innocuous garden of symptoms.
Mental status changes, as in the Seelig case, were the black boxes to be deciphered and quickly. The clock was ticking. What was causing cerebral injury? A stroke, a bleed, an embolism? Liver disease, renal failure, electrolyte imbalance, alcohol, drugs, prescription interactions? Sometimes a person’s cognitive decline is not noticed until she takes an innocuous over the counter medication.
During my training, the physician’s bible was a slim black hard cover book, Stupor and Coma by neurologists Plum and Posner from Cornell Medical School. They had looked at several hundred patients exhibiting changes in consciousness in their emergency room and established simple rules to determine if the cause was a structural intra-cerebral lesion (like a blood clot) or a metabolic derangement (intoxication, elevated blood sugar, skewed mineral levels etc.) Focal neurologic abnormalities, such as strokes, tumors or bleeds, which frequently cause weakness and reflex changes indicates a structural lesion. Except, of course, for hypoglycemia, a major exception, which mimics anything. The brain is unforgiving without blood or its mandatory glucose energy supply.
The effluvia of drug use that washes into our emergency rooms changes constantly. The Barbiturate generation became the Valium generation and then mutated into the Xanax/Ativan/Clonopin/Ritalin generation. Heroin and Cocaine have become Oxycontin and Mephamphetamines. Now prescription drug poly-overdoses taken with alcohol is number one on coroner’s lists around the country.
No matter what the cause, medical practitioners must perform a careful physical examination. We use a flashlight to check a patient’s pupil size and symmetry. Pinpoint pupils can indicate a narcotic overdose while fixed and dilated pupils are harbingers of brain death. We cradle a patient’s head in our hands, rapidly turning the head first to one side and then to the other. We look for “Doll’s eyes” – both turn symmetrically when we turn the head—if we turn the head left, the eyes go right. This indicates that the neuro-pathways are intact.
Important too are any changes in the patient’s level of consciousness that are Sherlock Holmesian in their subtlety. One patient, a fluent English speaker from China, with recurrent headaches reverted to Cantonese. He had a positive CAT scan for a brain lesion but was considered stable. An astute nurse, however, interpreted the sudden language shift as a sign that his brain pressure had changed. The subtle behavioral variance triggered her suspicion. The leaking lesion was putting pressure on his brainstem and he was wheeled to the operating room.
A tiny woman received a dose of medication for a man four times her size in a medication mix-up. She looked fine, but the staff recognized the mistake immediately and moved her to the intensive care unit. In a few more minutes, she would have stopped breathing far from trained staff in airway emergencies.
Changes in mental status, stupor and progression into loss of consciousness or coma do not follow a predictable trajectory. It can be sudden or follow a slow fluctuating pathway. If patients cannot be roused, even with a painful stimulus like a pinch, then they need intensive care monitoring. When people slip into a stupor or coma, they lose their gag reflex, making them susceptible to aspiration pneumonia. Respiratory depression results in lowered oxygen levels and damage to vital organs. Constant monitoring under controlled circumstances can be life saving.
Changes in consciousness challenge every emergency room every day. People are admitted for every conceivable issue and a large number of them, from every part of society, come in because of accidental overdoses. Our society is awash in drugs both licit and illicit. Every patient requires non-judgmental evaluation and monitoring. Let’s get back to basics. Careful ongoing neurological evaluations and targeted imaging and lab testing are good medicine. Carefully watching patients with a change in mental status in monitored settings is the standard of care. The Dolls Eye’s have stories to tell.