BROKEN SYSTEM: C2 FIXING IT


An elderly man is seen in a major hospital in a large city with neck pain following an automobile accident.  He is evaluated with neck X-Rays, read as normal, and discharged in a cervical collar.  A day later, he goes to another hospital in another large city with the same complaint and is found to have a fracture of C2, the second cervical vertebra, the so-called “hangman’s fracture”, because this bone is broken in hanging, compressing the spinal cord above where the phrenic nerve, which runs the diaphragm and breathing, exits.

The man will survive, and he will survive without deficits, although he will require a surgical procedure to stabilize the fracture.  Elderly people tend not to complain about head and neck pain the way younger people do.  When I practiced, new onset headache and neck pain in the elderly was something I took seriously.  You won’t read about this in books; a lot of neurology I learned in practice.  I noticed things, and I counted.

Had the man been rear-ended or even had a minor fall, he could have died suddenly.  At his age, with no autopsy, he might have been diagnosed as “heart attack,” with the outpouring of grief and comments about his life cut short.

And nobody would have noted the error.

The system will continue unchanged, with the first hospital’s staff thinking they provided high quality care, not knowing that they made a major error; they missed an odontoid (the name of that part of C2, the axis) fracture.  Somewhere in their clinical evaluation, they failed.  They don’t need to be sued, nor do they need to be publicly humiliated or embarrassed.  They need to learn from this error.   I learned medicine through gamesmanship and humiliation when I made a mistake; making people feel fearful, stupid or embarrassed (or sued) isn’t how they learn.

Ironically, 12 years ago, I went to this hospital and explained to the CEO why we needed a reporting system for medical errors.  He told me that they had one of the best systems in the country.  If that were truly the case, for this problem to occur a dozen years later says the quality of our programs to prevent errors needs immediate attention.

Doctors make mistakes.  They are human.  They make errors for all sorts of reasons: There may be insufficient knowledge, hurry, distractions, interruptions, lack of sleep, shift changes, miscommunications, and other reasons.  To assume a doctor is perfect is to deny reality.

What is needed is recognition of this reality and building of systems robust enough to find problems before they become critical.  How the system works is a matter of involving those who are involved.  It doesn’t come from the government, although if the medical profession doesn’t change, it will some day, and will have all the problems that come from government regulation.  Changes don’t come from the CEO or the head of the emergency department either.  They come from involving the doctors who work in this department, the nurses, the technicians, the people who first see these patients, the first responders who bring them there, and the radiology department.

The question to be answered is this:  How do we ensure we never miss this problem again?  The goal should be 0 misses, which means that part of the solution has to be followup with the patient, the way my veterinarian calls me at home the day after she does dental surgery on my cat.  If a cat can get better followup medical care than a human, then I have a major complaint with the medical system in America.

Hubris.  “World class.”  “We will take care of it.”  “We don’t need you.”  “Centers of excellence.” “99.99% of our patients do fine.”  The last I particularly worry about, because it means that 1 in 10,000 does not do fine, and if it is wrong-sided surgery, that is 2 cases a year in a busy hospital.  There are some things where percentages are appropriate, and there are others where counts are better.  There should be 0, null, zero, cases of missed odontoid fractures after an automobile accident.  Does everybody need a CT scan of the neck?  No.  Who should get one?  Look at the literature.  We put people in cervical collars routinely, when they have no neck pain, no neurological findings, no drug or alcohol abuse, and no tenderness to palpation of the neck.  Having all of these negatives was shown two decades ago not to require a collar.  Yet, we do it anyway, “just in case”.  In case of what?

I am telling the medical community to fix their broken systems, for they are broken when an important bone is broken and not recognized.  We have the ability to easily diagnose these problems when they occur, and we know enough about algorithms to know when we should work these patients up further, and when we do not need to.

I get follow-up surveys from nearly every company I deal with.  Amazon now surveys the packaging process.  I don’t know if anybody actually does anything based on these surveys, but if there is a mistake, they sure hear from me.  I would bet a great deal of money the hospital never called the patient to find out how he did.

If Comcast, for heaven’s sake, surveys, and if my veterinarian calls me to ask about my cat, it would appear maybe medicine ought to start doing the same thing.  Aviation has been investigating errors and disseminating the results for 40 years.  In 2001, I suggested medicine do the same.  I contacted 64 different groups.  Nothing happened.  Fine, don’t use my system, but put something in place to address this problem, because it happened once and it shouldn’t happen once; you guys aren’t learning from your mistakes, and you aren’t even counting.  

I wonder in the past 13 years how many hangman’s fractures were missed, causing death.

I wonder if in the next 13 years we will address the issue.  The smart money bets no.

 

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