The Anatomy of a Medical Mistake

Zeebrugge ferry victims remembered

On March 6 1987 the unthinkable happened. The roll-on roll-off passenger ferry The Herald of Free Enterprise left the Belgian port of Zeebrugge with it’s bow doors open, and capsized within moments, killing 193 passengers and crew:

The immediate cause of the sinking was found to be negligence by the assistant boatswain, asleep in his cabin when he should have closed the bow-door.

But the official inquiry placed more blame on his supervisors and a general culture of poor communication in the ferry company P&O European Ferries. The first officer was required to stay on deck to make sure the doors were closed, but apparently left the deck with the bow doors still open in the expectation that the assistant boatswain would arrive shortly. The boatswain, who is believed to have been the last person on the deck before the disaster was later asked why he did not close the doors given there was no one else there to do it.  He said it was “not his duty”.  Finally, the captain assumed that the doors had been closed when he set sail – he could not see them from the wheelhouse owing to the ship’s design and the fact that the shipping company had previously decided not to retrofit an indicator light in the wheelhouse.

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Serious medical errors often occur under similar circumstances, including flawed or violated safety protocols and failure of communication.

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For example, there were three instances of wrong side brain surgery at the Rhode Island Hospital in 2007. One time an experienced brain surgeon insisted to a nurse he knew what side of the head to operate on — but got it wrong.  Another time, a resident cut into the wrong side of a patient’s head after skipping a pre-op checklist.  In the third case, the chief resident started brain surgery in the wrong place, and the nurse didn’t stop him.

These errors happened despite required operating-room precautions adopted by the medical profession a few years ago to prevent such “wrong-site surgery” mistakes, including checklists, “time-outs” to double-check everything is correct, and indelible markers to show the surgeon where to cut.

These mistakes at Rhode Island Hospital suggest that such precautions can still be thwarted by the human element — ego and overconfidence on the part of surgeons, and timidity on the part of nurses too afraid to speak up when they see something about to go wrong.

Ongoing efforts to improve patient safety include: The use of information technology, such as hand-held bedside computers, to eliminate reliance on handwriting for ordering medications and other treatment needs. Avoiding similar-sounding and look-alike names and packages of medication. The standardization of treatment policies and protocols to avoid confusion and reliance on memory, which is known to be fallible and responsible for many errors.

However, the most important patient safety step is adopting a culture of patient safety at the hospital.

All staff must be encouraged to speak up if they identify a problem or mistake.

If the boatswain or first officer had simply flicked the switch to close the doors, or notified the captain they were still open, disaster could have been avoided on March 6, 1987.

Monmouth Neuroscience at the 2014 NJ Stroke Conference

We are happy to report that Monmouth’s stoke program was well represented at the 2014 New Jersey Stroke Conference earlier this month.

Two department of medicine residents, Drs Amor and Chan, presented our TIA center data in the poster session:

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Dr Holland gave a talk on the role of telemedicine in stroke rehabilitation.

MMC’s Stroke Program Recertified & Don’t Forget Our Stroke Support Group.

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Monmouth and HealthSouth’s Stroke Survivors Support Group

Where: The Cafeteria at The Rehabilitation Hospital of Tinton Falls

When: First and Third Wednesdays Each Month

Meetings are led by Stroke Survivor Dr Zaback.

Contact Shirley at 732-460-6742 for more details.

Malingering and Conversion Disorder, What’s the Difference?

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Both lead to mental or neurologic symptoms without any identifiable cause.

The difference is that while malingering is conscious and willful, conversion disorder is subconscious and involuntary.

What does this mean?

Well, malingering is deliberately feigning or exaggerating physical or mental symptoms motivated by a desire for financial compensation or avoiding work or military service:

One famous TV example of malingering was George Costanza, who faked a disability to get access to the executive bathroom:


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Another example, one of my personal favorites, is taken from Dirty Rotten Scoundrels.

Steve Martin, faking a disability to con money out of Glenne Headly, is tormented by competing con man Michael Cane who is pretending to be a doctor:

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In conversion disorder, or hysteria, the mental or physical symptom develops subconsciously in response to some stressful event or situation, and the affected patient truly believes they have a physical problem.

The Freudian theory suggests that a painful experiences is consciously repressed as a way of managing the pain, but this emotional charge is  somehow “converted” into the neurological symptoms.

In this scene from Talladego Nights, Ricky Bobby (Will Ferrell) emotionally traumatized by an accident, believes he is paralyzed.

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In this (long) clip taken from Speed Racer, Speed challenges a washed up racer to “wake up” his paralyzed R arm and race again:

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Finally, there many cases of both malingering and conversion disorder brought on by the stress of war in active duty military, and this recently declassified WW2 documentary from 1946 “Let there be light” shows examples of “Shell ShockedG.I.s undergoing some unconventional treatments.

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Mass hysteria is a particularly interesting social phenomenon where many people in one group together all share the same collective delusion of a disease, fear or exposure:


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Perhaps the most recent example of mass hysteria occurred in LeRoy New York in 2011-2012.   The 12 high school girls all developed Tourette-like symptoms , which led to extensive testing of their school for toxins.  The were all ultimately diagnosed with mass hysteria and conversion disorder:

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So, is there any concrete way to differentiate malingering from conversion disorder?

The answer is, maybe.

There are many clues gleaned from the physical exam that suggest a patient’s findings are non-organic, but this won’t tell you if the process is volitional or subconscious.

In a recent study, investigators compared PET scans from healthy individuals instructed to feign left arm weakness operating a joy stick, compared to controls who did the movement tasks normally.

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The feigners both had abnormal hypofunction of the right anterior prefrontal cortex not seen in the controls.

Perhaps a future objective test for malingering?

Concussion’s Axis of Evil

The term concussion is derived from the Latin word “concutere” which means “to shake violently”:

This term is used to describe a head injury associated with a temporary loss of brain function, including impaired consciousness, cognitive dysfunction and/or emotional problems.

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Concussion Center

To fully understand Concussion’s Axis of Evil, one need look no further than the brutal world of professional boxing and it’s neurological complications.

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One of the most savage beatings any fighter every received occurred on July 4, 1919 in Toledo, Ohio, when 24 year old Jack Dempsey destroyed 37 year old Jess Willard to become the Heavyweight Champion of the World.

One can easily spot the effects of concussion in Willard as he sustains blow after blow to the head, and he develops unsteady gait, erratic behavior (failing to avoid punches and protect himself) and ultimately unconsciousness.

New Jersey’s own Harrison S. Martland MD (1883-1954) was the first to report in 1928 that repeated beatings of this kind could lead to a delayed permanent neurologic syndrome referred to as punch drunk syndrome.

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His observations went largely unheeded.

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Muhammad Ali (born as Cassius Marcellus Clay in 1942) was only 22 when he became word heavyweight champion in 1964, almost 40 years after Martland’s paper was published.

Here is with Liberace in 1964:

Almost 10 years after that performance, Prof Corsellis reported further clinical and pathological features of punch drunk syndrome in his 1973 paper “The Aftermath of Boxing”.
Here’s data from one of his cases:

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By the 1980s, reports of abnormal brain CT scans in professional boxers had reached the popular media (Sports Illustrated, 1983):

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By 1983, Muhammad Ali was retired from professional boxing,

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and soon to be diagnosed with “Parkinson’s disease”.

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Here he is on the Today show with Bryant Gumbel in 1991:

Here he is in 2009:

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Obviously, repeated head trauma, and it’s consequences, is not unique to boxing:

concussion9John Grimsley (1962-2008) was a linebacker for the Houston Oilers.  He retired in 1993.  In 2008, aged 45, he was killed by an accidental gun shout wound to the chest.

His brain was examined as part of an ongoing study by Boston University’s Study of Traumatic Encephalopathy.

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concussion10His brain showed the same pathologic changes as the Punch Drunk boxers.

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This syndrome, more commonly referred to as Chronic Traumatic Encephalopathy, is now known to have occurred as a consequence of repeated head trauma in many other sports, including soccer, hockey, horse-racing and wrestling.

College football and amateur soccer players have been shown to have impaired performance on neuropsychologic testing, worse with increasing number of concussions.

Then, there’s the Second Impact Syndrome (SIS).

SIS is said to be a rare, often fatal, traumatic brain injury that occurs when a repeat injury is sustained before symptoms of a previous head injury have resolved.
Although limited to single case reports, and disputed as a discrete syndrome in the scientific literature, SIS cases are young athletes and have become high profile in the media:
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Click here to find out more about this case.

It has become clear that it takes athletes longer to recover from repeated that single concussions:
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This data, as well as SIS cases, has led to a concern that the presence of ongoing concussive symptoms are a significant risk factor for further injury to occur, and that any residual symptoms should mandate restriction for further contact sport in young athletes.

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Finally, it is know that concussions are under-reported by high school players.

A 2004 survey of 1500 varsity football payers in Milwaukee disclosed that although 15% had sustained a concussion during the season only 50% reported it to their coach or trainer.

So there we have it, Concussion’s Axis of Evil:

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And the solution?

The Allies Against Concussion:

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Click here to read more about how we have put these measures into effect at Monmouth Neuroscience Institute.

Click here to find out more about the Matthew J. Morahan III Health Assessment Center for athletes at Barnabas Heath.