Wednesday, October 29, 2008

An Unwanted Journey: Day 1070 - Root Cause Analysis

One of my friends (he'll recognize himself immediately when he reads this) was often a proponent of solving operational problems through a tool called root cause analysis (RCA). It isn't rocket science, but in the hands of someone like him, it truly shines as a way to discover the full extent of a problem whose outlines are only modestly appreciated. Then, it continues by employing questions and analyses which sort through the many candidate reasons why the problem arose in the first place, looking for the one, two, or more root causes and secondary causes.

It always struck me, when working with him on problems in which this formal analysis was used, that its applicability went far beyond manufacturing and operational systems in general, right to everyday life issues and even recurring geopolitical controversies.

If the events of the past week are typical, then RCA should be applied by medical staff and patients alike, especially when one realizes that treating symptoms sometimes seems more important to both parties than dealing with the underlying causes.

My wife and I just returned from a 5-hour visit to the emergency ward of the Grand River Hospital. I finally acceded to my wife's demands because the pain had, yet again, become unbearable, and the symptom relief approach I had been taking was itself accentuating the pain in the lower back and abdomen. "She was right, and I was wrong!"

After describing the new pain in the lower back, the recent problem of failure to void my bladder, and the continuing issue of diarrhea and constipation, we went into what I think is a standard RCA approach. We took a urine sample (that was very difficult in itself). We performed a bladder scan and found that I was retaining urine, at least 717 ml. We catheterized and let the bladder drain until 1200 ml was in the bag. We did x-rays on both the bladder and the rectum, hoping to see a correlation between the two organs. We did. The rectum and colon had evidence of stool backup and stagnation.

The doctor then explained the anatomical reasons why constipation might be applying pressure to the bladder, thereby preventing voiding in a natural way. In addition, when he took a medical history, he discovered that I had stopped a 2.5 year Flomax prescription in late July or August. He then explained how doing so could account for a gradual failure of the bladder to void, leaving larger and larger volumes in the bladder until I became symptomatic.

Only then did he recommend a course of treatment to deal with the root causes he had just proposed. Start up the Flomax again over the next few days. This would gradually aid the bladder in voiding entirely rather than partially. Wear a special catheter and leg bag for 2-3 days to void the bladder, thereby allowing the bladder some time to heal and to let the Flomax do its work. As a side benefit, I wouldn't have to deal with self-catheterization (I became pretty good at it in 2006, but doing it once instead of several times a day definitely has advantages for my personal comfort levels). Finally, if my oncologist agrees, I might actually need a prescription for a laxative after all this time spent on treating diarrhea.

Some of the secondary causes we discussed included pain killers in general, oxycodone specifically. These almost always are responsible for some level of constipation. The irinotecan, although it generally has the effect of increasing diarrhea, will sometimes do the exact opposite.

One of the things we didn't talk about but which strikes me as essential is the problem of communication. I noticed at our consultation on Monday that the family physician specializing in oncology and I were using words like diarrhea and bowel movement in slightly different ways. This isn't just a matter of inconvenience, it is directly related to the measurements one uses to determine which approaches to take to symptom relief. Here's one example. If by diarrhea, you mean either watery stool or more frequent stool elimination, then you might be treating something that doesn't exist. If by bowel movement, you mean any elimination from the anus, then obviously the count of bowel movements in a day can be arbitrarily and artificially inflated, thereby leading to treatment of symptoms which don't really exist.

In my own case, I was using the larger definition of diarrhea, while the doctor was using the narrower definition of stool that includes a watery, runny component. By my definition, I had diarrhea; by hers, not so much. It's even worse with bowel movements. I was equating trips to the bathroom involving elimination of stool, no matter how minimal, with bowel movements. She was using it in the narrower sense of counting only those eliminations in which there is "substantial" and "greater than normal" watery consistency of stool. This meant my counts were often double or triple what hers would have been. Is it any wonder that I might have been following a treatment protocol for diarrhea when I should have been following one for constipation?

When we arrived home, I took half the normal dosage of oxycodone for pain relief. But even at the time, it was clear to me that having voided the bladder left me with very little pain at all. In fact, I may simply go "cold turkey" on the pain medications later in the day.

I know that this is a lot of detail for something that most people would rather not discuss publicly. But, given the dangers inherent in treating symptoms rather than discovering root causes, and given the very significant problems of communication and definition of terms, it's clear to me that medical staff and patients should be having these conversations and doing root cause analysis.

Instead of having a week from hell, it might have been a somewhat interesting journey through purgatory.

1 comment:

Anonymous said...

Don, I have often felt that our language leaves much to be desired, and also leads to many misunderstandings. Oh, if we could just communicate directly from our heart.

I am so glad that you are free from that terrible pain.

Love, Mom.