Saturday, December 09, 2006

The cruelty of a profession

Everybody makes mistakes. Its part of life. And all mistakes have a cost. Some mistakes cost nothing like making a spelling mistake while blogging - you press a button and the mistake is gone. Others are more costly - like forgetting your wallet somewhere. And some mistakes may make you broke like making a tactical error in business. A mistake may be costly but not in terms of money like losing a child in a busy mall.

But the most unforgiving of mistakes are the ones we as medical professionals make. A mistake on the part of a medical man usually translates into direct damage to the patient. And yet thats all that they are ....mistakes ....which anyone can make.

As a doctor gains in experience, the less mistakes he makes. So when you look for an experienced doctor, its not because he'll do a better job but its because he's less likely to make a mistake.
Some of the common mistakes we as medical practitioners are guilty of are

  1. Wrong dosages of drugs - Unfortunately things can get ugly sometimes if a doc makes a mistake, especially if he is dealing with a child.
  2. A wrong diagnosis - To say that medicine is vast is an understatement. It is very possible for a doctor to miss a diagnoses no matter how well read or bright he is. And when diagnoses are missed, patients suffer.
  3. An improperly done surgery - This is a technical aspect. Just as a musician or a soccer player gets better with practice so does a surgeon. Most surgeries have a learning curve. Some learning curves are steep meaning one has to do that surgery many times before he can perfect it. So if he is going to be good only after 100 surgeries, what about the 99 he didn't do too well ? In those 99 he has made mistakes and many of those patients have suffered. Can anyone avoid that ? not really. There is no other way to make an experienced surgeon.
  4. A surgery done when none was needed - This happens when a surgeon is aggressive and inexperienced. In his early days, after a few successful surgeries a surgeon thinks he is invincible. He can cure anyone with his knife. He is God. Experience eventually humbles him. He realizes that many patients are better left alone. This is also kind of a learning curve. Sometimes a surgeon would do an unindicated surgery purely for monetary gains. That is vicious and cannot be forgiven.
  5. Fatigue mistakes - These are a huge number of mistakes a doctor is likely to make when he is tired. And believe me doctors get tired. If you knew the kind of hours a doctor puts in you would be shocked. And if he is a resident doctor I'd be shocked if he didn't make a mistake. What would happen if a truck driver fell asleep while driving? Now replace that driver with a doctor ....
  6. Forgetfulness - just a simple act of forgetting something can land a doctor into so much trouble. Forgetting to remove a tourniquet, forgetting a mop inside the wound .... all perfectly plausible mistakes which can be made by anyone and yet unforgivable results.
  7. Carelessness - a doctor omits to do a vital step as he was in a hurry to reach the party. Sounds so horrible. Rid him of his degree and put him behind bars. But aren't we all careless every now and then?
When a doctor does make a mistake are usual reaction is that of anger. How could someone give him a degree? He is so incompetent ! I will take him to court. Of course some mistakes are not forgiven by the courts so I won't stop you from going. But If you think about it with a cool head, you will realize that everything went wrong because of a mistake. A mistake that anyone could have made. No doctor is out there to harm you. It does a doctor no good to harm a patient. His reputation goes for a toss. Hell it doesn't even make economic sense to harm a patient. But still complications happen all the time......the reason - a simple mistake.

Monday, December 04, 2006

A scary phase in total knee arthroplasty

Total knee arthroplasty(TKA) has revolutionized the care of patients with knee pain. This is one surgery that has given excellent results and has proved to be a boon for the arthritic knee.

Even so, TKA has its problems -

  • By nature a prosthesis has a fixed life. One day it is going to fail. Just as a new car becomes old and starts breaking down, similarly a TKA prosthesis will give way in time. Much of the current research is concentrating on improving the life of the artificial joint.

  • The second problem is that of reproducing the normal knee movements. The normal knee is a complicated joint with sliding, gliding and rotation occurring between the two surfaces as the knee bends. It is difficult for an artificial joint to mimic these movements. Hence an artificial joint is unable to flex (bend) as much. Knee bending is important especially in India for cultural and social reasons. Driven by this patient demand, there is much pressure to make designs which allow more bending (high flexion).

There are many new advances being made in this field. Many of these are truly beneficial, others still to be proved and a few of them are quite useless. Lets review some of these.

  1. Unicondylar knee arthroplasty - Here only one compartment of the joint is replaced (usually the medial). The proposed advantages are that the minimal damage is done to the knee, the other 2 compartments are preserved, no ligaments are cut, surgery can be done in a minimally invasive way, revision to a total knee at a later date is easy. The good news is that the results of the unicondylar knee have come in and many centres are showing over 90% survival for 15 years. The bad news is that only a few patients qualify for this surgery (approx 7% of total patients needing surgery for knee arthritis). This surgery has disastrous results in improperly selected patients (beware of the over enthusiastic surgeon). Another thing the surgeon will not tell you is that a high tibial osteotomy, which is a simpler and cheaper procedure, works just as well. Further revision to a total knee has been cited by many authors to be difficult, disproving an earlier claim.

  2. Minimally invasive surgery (MIS) - There is a lot of interest and media hype about minimally invasive surgery. Unicondylar knees are usually done the MIS way. TKA is also being done with MIS with or without the help of computer navigation. MIS basically means to do the same surgery through a smaller incision with lesser trauma to tissues. Well this concept sounds very appealing, doesn't it ? MIS surgery does allow faster rehabilitation, but the results are the same at the end of 3 - 4 months. Further, because access is not as good as the routine incision, some surgeons have reported errors in making the bone cuts and therefore in the position of the final implants. MIS is not as big an advance as it is being promoted. The advantage gained is not worth it if it is at the cost of implant alignment. I feel a properly aligned routine TKA would work just as well.

  3. Computer assisted surgery (CAS) - Does computer navigation improve TKA results? The only thing that has been proved, is that it improves coronal alignment. Whether this translates into better longevity of the joint is still to be proved. CAS is as good as the operating surgeon. The surgeon needs to feed the computer information about the patients body parameters. He does this by placing probes at fixed points which transmit information to the computer via infra red rays (referencing). Using this information the computer creates a virtual model of the patient's knee. Over here lies the problem. There are a lot of errors in referencing. If wrong information is fed to the computer, wrong information is going to come out. Garbage in is garbage out. And yes, let me make it clear, the computer is not doing the surgery. To summarise, CAS is here to stay and will be indispensable in the future, but today it is of doubtful benefit in routine cases. However it is very useful in complicated cases, like those with deformities.

  4. High Flex Knee - This is one of the new knees that have come into the market. As the name suggests it promises a greater degree of bending of the knee by virtue of its design. But post operative knee flexion depends on many things such as the preop range of motion, the type of arthritis, the weight of the patient etc. Some patients will get flexion and some will not, no matter what implant. So all that this implant does is give those patients who were anyways destined to get good flexion, some more flexion. Even this is doubtful as many reports have come in that the results are the same, high flex or no high flex. Besides there is a real concern that this design may actually accelerate prosthesis damage by increasing stresses.

  5. The rotating platform Knee - This is another attempt to reproduce normal knee movements. By virtue of its design this knee allows some rotation that usually takes place in the normal knee. The proposed advantages are more knee bending and less prosthesis ware and a longer prosthesis life. Unfortunately most reports of long term follow up show no difference in either knee function or prosthesis life.

To conclude there are many attractive & new things happening in knee arthroplasty. A lot of people out there are trying to sell you something new claiming it to be better. But new is not always better. The routine TKA is still the gold standard and it has been proved time and over. This is a very scary phase in TKA surgery and I warn the patient/consumer to do their homework thoroughly before deciding to go ahead with a new and fashionable surgery.

If you liked this post sign up to get regular updates.

Friday, December 01, 2006

World AIDS Day........Mumbai Doctors Walkathon

Ranbaxy organised a Mumbai doctors walkathon on 1st december '06. The walkathon took off from Nariman point at 7:30 am. The doctors turned up in a huge number. Here are some pics of the event.

Bakhtiyar & Tanaz were there.....

So was A.N. Roy.......

The walkathon kicks off !

The docs on the road. Wonder why it was not a marathon ? Are mumbai docs in no shape to run ?? Anyways it was good effort for AIDS awareness. Great going Mumbai docs !