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• What will be done to prevent someone else being harmed in the future
  Oscar, M Jolobe
  Published on: 26 November 2020

• Published on: 26 November 2020

  What will be done to prevent someone else being harmed in the future

  • Oscar, M Jolobe, retired geriatrician manchester medical society

  The soul-searching analysis by Daniel McKenzie deals with the scenario where both the doctor and the patient recognise that something went wrong(1). The dynamics are different when it is only with the benefit of hindsight that it is only the professionals who realise that, all along, they have been inflicting iatrogenic harm on their patients. Even in that scenario what matters is "What will be done to prevent someone else being harmed in the future?".
  The thrombolytic treatment of ST elevation myocardial infarction(STEMI) is a case in point. That treatment strategy was initiated in 1986, and it soon became the standard of care for STEMI(2). Further down the line, in September 2020, a literature review identified 138 cases(with accompanying case histories) of dissecting aortic aneurysm(DAA) characterised by STEMI-like ST segment elevation. These cases were published during the period January 2000 to March 2020(3). Arguably, there must have been, at least, the same number of cases of STEMI-like DAA in the 20 year period following the introduction of thrombolytic treatment of ST elevation myocardial infarction. At the very least, some of those cases must have been harmed by thrombolytic treatment.
  Why does that matter in September 2020? It matters because thrombolysis is "back on the agenda" for some myocardial infarction patients with ST segment elevation(4). All this, without the precaution to rule out DAA either by point-of-c...

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  The soul-searching analysis by Daniel McKenzie deals with the scenario where both the doctor and the patient recognise that something went wrong(1). The dynamics are different when it is only with the benefit of hindsight that it is only the professionals who realise that, all along, they have been inflicting iatrogenic harm on their patients. Even in that scenario what matters is "What will be done to prevent someone else being harmed in the future?".
  The thrombolytic treatment of ST elevation myocardial infarction(STEMI) is a case in point. That treatment strategy was initiated in 1986, and it soon became the standard of care for STEMI(2). Further down the line, in September 2020, a literature review identified 138 cases(with accompanying case histories) of dissecting aortic aneurysm(DAA) characterised by STEMI-like ST segment elevation. These cases were published during the period January 2000 to March 2020(3). Arguably, there must have been, at least, the same number of cases of STEMI-like DAA in the 20 year period following the introduction of thrombolytic treatment of ST elevation myocardial infarction. At the very least, some of those cases must have been harmed by thrombolytic treatment.
  Why does that matter in September 2020? It matters because thrombolysis is "back on the agenda" for some myocardial infarction patients with ST segment elevation(4). All this, without the precaution to rule out DAA either by point-of-care transthoracic echocardiography(TTE) or by transoesophageal echocardiography(TOE). The former is non-invasive but suboptimally sensitive, the latter is invasive but much more sensitive.. To mitigate the suboptimal sensitivity of TTE one strategy would be to maximise the pretest probability of DAA by compiling a risk score which encompasses history of backache(which does not need to have a "rearing" quality), documentation of interarm blood pressure difference, presence of the murmur of aortic regurgitation(optimally detected by the Vivid-7 system; GE Medical, Milwauwkee, Wisconsin, USA)(5), focal neurological symptoms and signs, and mediastinal widening on chest radiography. A high pre-test probability of DAA would be sufficient to invalidate a TTE which had failed to detect stigmata of DAA.
  Our patients are not aware of the dynamics that come into play when they present with chest pain and a STEMI-like electrocardiogram. They take everything on trust. It would be unconscionable for us to knowingly put them in the way of iatrogenic harm by not heeding the lessons that can be gleaned from the literature on STEMI-like DAA.

  I have no funding, and no conflict of interest.
  References
  (1) McKenzie D
  What to do when things go wrong
  Heart 2020;doi.org/10.1136/heartjnl 2020.316539
  (2) Van de Werf
  The history of coronary reperfusion
  Eur Heart J 2014;35:2510-2515
  (3) Jolobe OMP
  Clinical characteristics in STEMI-like aortic dissection versus STEMI-like pulmonary embolism
  Archives of Vascular Medicine 2020;4:019-130
  DOI:29328/journal.avm.1001013
  (4) Vallabhajosyula S., Verghese D., Subramanian AV et al
  Management and outcome of uncomplicated ST segment elevation myocardial infarction patients transferred after fibrinolytic treatment
  Int J Cardiol IJCA-28800(Article in Press)
  (5)Draper J., Subbiah S., Bailey R., Chambers J
  Murmur clinic. Validation of a new model for detecting heart valve disease
  Heart 2019;105;56-59

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  Conflict of Interest:
  None declared.

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