A Previously Unreported Complication

WHEN I READ HUGH G. CALKINS’s  journal article about what happened to Pam, I thought at first that he is not a very good writer. But now, after having read it many times, I see it as a masterpiece of mind-bending logic. An article to report a previously unreported complication, which cites two previous reports of the complication being reported.

Here are two sentences in the order in which they were published in the peer-reviewed Journal of Cardiovascular Electrophysiology Vol. 13, No. 8, August 2002:

“Entrapment of a circular mapping catheter in the mitral valve apparatus during focal AF ablation is a serious and previously unreported complication. A review of the literature reveals that catheter entrapment in the mitral valve apparatus has been reported in association with catheter ablation procedures.”

The fact that this makes perfect sense to the author and his peers illustrates a main aspect of this story: The melding of Science, Medicine and Academia at teaching hospitals has rendered the patient an abstract part of the healing equation.

Catheter injury to a mitral valve, the complication that took Hugh Calkins by surprise in Pam’s case, has long been recognized by the American College of Cardiology as a risk of any cardiac catheterization because it is common sense: “Certain risks are associated with RF ablation. They include the general risks of any cardiac catheterization, such as valvular damage…” Hein Wellens, 1999.

“The catheter should be carefully manipulated in order to avoid entrapment into the mitral valve apparatus.” Hindricks G: Eur Heart J 1993. Hugh Calkins himself has written that catheter manipulation can cause valvular damage, and he should know, because he was manipulating a catheter that damaged someone’s heart valve in 1991.

So why the compulsion to publish a story about a botched ablation? Especially since, according to what the attending physician told the patient and her family, the error occurred because he’d taken his eye off the ball.

Most doctors would be embarrassed.  But if you are helping to field test equipment and you can present it as news, a scientific discovery, then you can add another title to your list of publications. And that’s what it’s all about. In order to stay on top of the field you’ve got to publish. The patients become statistics, they come and they go, and after a while a certain detachment begins to take hold.

Not surprisingly, an elitist attitude pervades the upper echelons at hospitals like Hopkins. As a Harvard graduate recently commented, “In medical school we were actively encouraged to be leaders in medicine, and not necessarily good doctors.”

Research and academic professor/physicians are generally out to prove a theory or test a procedure or product. You are not a patient coming to get well, you are one of forty patients in a defacto medical trial. You are an endpoint for a study,  a chance to try out a new technique or device.

Your body is the proving grounds for newcomers to medicine and their new hardware. Here is an extract from an editorial in the Journal of Thoracic and Cardiovascular Surgery, titled Surgery as Spectacle by Dr. Duke Cameron of Johns Hopkins. It is a thoughtful piece discussing the pros and cons of telecasting live open-heart surgery. The words in parentheses are Dr. Cameron’s, in the original text.

“Several of my colleagues have also been witness (rhymes with accomplice) to intraoperative disasters… including patient deaths in what should have been straightforward procedures… and who later confessed a sense of collective guilt and shame that discouraged them from pursuing their own experience with the new technique.

“I once viewed a live telecast valve repair that resulted in a clearly unacceptable outcome but was tolerated because… I suspect… the surgeon did not want to publicly acknowledge failure and replace the valve.”

A clearly unacceptable outcome was tolerated.

Tolerated by whom? Maybe witness doesn’t really rhyme with accomplice, but the point is well taken. A witness to a crime may be inclined to report it and to help the victim. An accomplice would not. I doubt that Dr. Cameron and his colleagues confessed their complicity in these intraoperative disasters to the families of the victims.  Shame and guilt will only go so far. Most likely, the attending surgeon came out shaking his/her head and explained to somebody’s wife or mother or son that there had been a complication, a very rare complication.

And most likely, the stunned family member, having been trained to believe in the infallibility of medicine, a reader of US News & World Report, said thanks, Doc, I know you did the best you could, and they buried their loved one and tried to go on…

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