How many errors to kill a population?
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I have been a physician since 1974, and I have always believed in what I do — and I still do.
One aphorism that I have never liked, but which is probably true, is that it takes three medical errors to kill a patient. That sounds ghastly, but it generally reflects that most human bodies — and their associated spirit — are amazingly robust.
If a physician or other health care provider makes one or two errors of judgment or management, it usually does not result in the death of a patient. However, a third error often can prove fatal.
Although that sounds trite, when I have reviewed cases at various medical conferences or tumor boards — or in association with my earlier interest in medico-legal work — it often plays out that way, to the great detriment of the patient concerned.
My friend and co-editor, John Sweetenham, MD, wrote a thoughtful piece on COVID-19 in the last issue and — as usual — I enjoyed reading it. To focus on the same major topic in serial editorials of HemOnc Today is unusual, but this is such a cataclysmic time in modern history that I don’t feel I’m overstepping the mark.
Ignoring first principles
It was interesting to note that John’s team at UT Southwestern Medical Center has taken a very similar stance to ours at Levine Cancer Institute, as outlined in a paper published online this month in Journal of Oncology Practice.
Although as John correctly notes there are scant data to support our approaches to patient care, at least we can draw consolation that we are handling this similarly from first principles.
Working from first principles is a time-honored tradition of clinical medicine. It’s what you do when you have little information but know something about the general situation from basic or clinical science, and you have to make a (hopefully) good and quick decision to save a patient’s life.
This brings me to the theme of this editorial.
It is clear to me that our nation is like the patient of a physician who has made two of the three potential errors. Unlike the situation in good clinical medicine when decisions are taken from first principles, it appears that our governmental leaders en masse have been frozen by uncertainty and ignorance, and have completely ignored the first principles derived from international experience with SARS-CoV-1, Ebola and Zika virus.
This brings me to the question: How many severe errors of judgment does it take to wipe out a population? What might those errors of judgment be — and how many more will our leaders make?
My evolving list is:
- Federal and state governments, and many health agencies, having been asleep at the helm amid the serial warnings regarding the dangers of a pandemic and allowing the agencies and supplies to deal with such an event to be dangerously depleted.
- Refusing to accept the rising danger to the world, once the lack of disclosure of the Wuhan events surrounding the onset of COVID-19 had been overcome.
- Failure to close the borders and restrict travel immediately. Singapore and Taiwan have shown very clearly that responsible government action to restrict the importation of dangerous substances — viruses in this case — can have a huge impact on the morbidity and mortality of an epidemic.
- Claiming that this rising catastrophe would spontaneously resolve within a short period, without any specific action.
- Absence of appropriate coronavirus testing, with the CDC insisting that it should be the only agency to have the test ... and then completely botching it. Maintaining power and control is never desirable in a government agency that really doesn’t need that authority for its role.
- Suggesting that masking is not necessary, when the driver was a fear regarding the absence of available masks. And why did it take the CDC and federal government 3 months to decide that a reasonable option would be to fold a piece of cloth, insert a coffee filter, attach two rubber bands and voila, a mask? The Italians and Chinese showed the impact of masking and social distancing months ago, so what new fact led to the change in our country?
- Deciding that civil rights and the Constitution should preclude a small number of states and cities from enacting social distancing rules, thus putting the rest of the nation at much greater risk.
- Vouchsafing ad libitum that chloroquine derivatives probably work and have no potential toxic effects, leading at least to a false sense of security and possible harm.
‘It is up to us’
The CDC has been both asleep at the helm and impotent to fulfill its obligations to our community. I presume it is because of fear of government retribution, but that still represents dereliction of duty in my book, and I have no expectation that its leaders will resign in disgrace nor face any penalty.
I also would issue a gentle caution to the FDA, which is one of my favorite agencies (and is not on the above list).
Of course you must attempt to please federal leadership, but be careful not to drop your testing standards so low as to allow test kits that have high false-positive or false-negative rates into our nation, and beware approving drugs that might not work and are potentially quite harmful for patients experiencing this viral explosion. You and I know that dropping your standards will align you with leaders who will be judged very harshly by history.
So, now what? It is up to us to do what we can.
Novel therapeutic approaches are being assessed as rapidly as possible.
Our ingenuity is helping. For example, one of my colleagues has developed a 3D printing operation — with the help of his daughter and sister — that has been able to produce thousands of face masks, providing added protection when N95 masks have been in short supply. Others have developed a four-way valve that allows ventilators to help four patients at a time.
Folks, we are on our own, and we will have to take control back and save ourselves using our courage, ingenuity and social distancing (perhaps our best weapon for the time being).
I write on this topic to represent the silent population of thousands of health workers and/or first responders who place themselves at risk each day, many of whom do so without adequate protective equipment.
This is outrageous, as is the report of a hospital that fired a physician for speaking out about the lack of personal protective equipment.
I have lost all confidence — such as it was — in most of our political leadership, and just hope that the dictum “physician, heal thyself” will work this time.
Reference:
Raghavan D, et al. J Oncol Pract. 2020;Published online ahead of print.
For more information:
Derek Raghavan, MD, PhD, FACP, FRACP, FASCO, is HemOnc Today’s Chief Medical Editor for Oncology. He also is president of Levine Cancer Institute at Atrium Health. He can be reached at derek.raghavan@atriumhealth.org.
Disclosure: Raghavan reports no relevant financial disclosures.
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