I write this blog to try to bring transparency to medical practice. In trying to explain and demystify medicine, I’ve found that I use my ‘patient hat’ to explore topics that you want to know about. Even when I wear my ‘doctor hat,’ there are many things that remain inexplicable to me.

As one example, I’ve often wondered: Who had the shocking boldness to try stimulants on people with attention deficit disorder?

Here’s how I imagine that conversation must have gone:

Mmm Mmm Good!

Psychologist: We keep getting these hyperactive kids referred to us for therapy. I wish there was some pill we could give them to calm down.

Researcher: Have you tried sedatives?

Psych: Yes, but the parents complain that their kids just sleep all the time and aren’t doing better in school.

Researcher: Wait! I know! Let’s give them Ritalin and see what happens!

Psych: [Groans.]¬†Oh sure, great idea! Take some amped up kids and give them uppers. Yeah, that’ll work.

I remember learning about this in medical school. It still doesn’t make any sense to me. But it works. Was it clever neuroscience or just dumb luck?

Similarly, there are often examples of medical errors where the natural reaction is, “How on earth could that happen?”

The most outrageous of these are the stories of wrong site surgery. Imagine going in to have part of your leg amputated (not so easy, I imagine) then waking up to find out the wrong leg had been removed. That would be pretty upsetting. This is the reason that medical authorities have come up with the idea of “never events:” things that should never be tolerated in the world of medicine.

Well, add one more to the list.

Last month a hospital in the U.S. admitted that a kidney was transplanted into the wrong patient. Oops!

As egregious as this seems, it’s not so difficult to imagine. All kidneys look pretty much the same. And even though they are typed (i.e. blood typed) and have identification, it can be easy to confuse things like “the type O kidney goes into the blood type B patient (type O is acceptable to anyone)” or “we need to save that type O kidney for this type O patient.”

Huh? I’m confused already, and we’re only talking about one kidney. Imagine having several operating rooms going at one time (multiple donors and recipients), and you can imagine it’s not that hard to get confused. One transplant surgeon told me that at big centers that do multiple transplants on the same days, the error that happened is not all that far-fetched.

Two good things happened here:

  1. The recipient of the wrong kidney didn’t wind up getting sick or rejecting the kidney, since in fact it was a type O (universally accepted) kidney.
  2. The hospital admitted its error and apologized for the mistake. Oh wait. At least I hope they did. They did in fact temporarily shut down their program to investigate the error and hopefully find ways to prevent something like it from happening again. [As of this post, they are up and running again.]

Which gets me to the bottom line of this week’s post: March 6-12th is national Patient Safety Awareness Week, so declared by the not-for-profit National Patient Safety Foundation. If you’re interested further, there are some worthwhile blog posts and podcasts offered up on the interesting “Engaging the Patient” blog, hosted by the for-profit, but high-purposed, Chicago-based Emmi Solutions. [Imagine: a business created around the idea of improving patient experience…..]

I’d be interested in your thoughts on the quality and content of their blog. Anyone knowing the origin of psychostimulants for ADD is also encouraged to comment.

GlassHospital