The Hebrew Hippocrates
So we were taking care of a man who happens to be a patient of one of the few original House doctors. The man has a heart condition for which he needs blood thinners, lest he eventually suffer a stroke. He just went to surgery, which usually means bleeding, at least until everything heals. We duly weighed the pros and cons of stopping the blood thinners, temporarily; some said the risk of bleeding after surgery was greater than the risk of stroke in the perioperative period.
The House Doctor, in reply to these concerns about the dangers of blood thinners, pulled out an index card from his pocket, where it was written (in Hebrew, which he had to then translate for us Gentiles), "The art is long but life short; the crisis fleeting, the experience perilous, and the decision difficult." And so we have to thin the guy's blood, q.e.d., even if that means he bleeds to death.
That was yesterday. Today, CODE BLUE sounds out from the man's room, where blood is literally erupting from the surgical wound like a volcano.
This Hebrew Hippocrates will one day retire, a terrible shame for posterity and a tremendous blessing for patient safety.
Ed.: The man did pull through, but I think that takes away from the story, don't you?
Ed.: The man did pull through, but I think that takes away from the story, don't you?
As I understood the problem, both of the options of the physician were potentially dangerous. In the field of Decision Theory, they try to minimize the sum: loss of each possible outcome, times the chance of it occurring given the evidence.
ReplyDeleteAs I interpret you and Hippocrates, even in cases of very high risk, the physician still owes it to patient and practice to maximize his chances.
Good to read you again, Dr. Parker.
There are good data on this very situation, derived in exactly the fashion you describe and validated by rigorous review of clinical data. Each outcome (stroke or other thrombotic complication, bleeding, etc) is assigned a value (death = very bad, disability from stroke = bad, bleeding requiring re-operation = bad, bleeding requiring transfusion = a little bad, and so on) and the odds of each outcome are then multiplied through, resulting in a "cost" of each arm in the decision tree. In other words, this is a quandary that comes up all the time and We (the royal plural of modern medicine) do know the safest thing to do in this situation.
ReplyDeleteThe intent was not to second guess the decision in this particular case, rather to mock the way the seemingly sage old physician's poeticism. The ancient aphorism of Hippocrates (which was written in Greek, not Hebrew, btw) would support us and recognize our unease whichever way we had decided to proceed, but the data would only support us one way. No reason you couldn't invoke both, but only invoking the former when it is the latter that actually helps is absurd.