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Why nothing's ever idiot-proof

Copperfield suspects few medical procedures can be made truly idiot-proof. Someone's always working to perfect a better idiot

Copperfield suspects few medical procedures can be made truly idiot-proof. Someone's always working to perfect a better idiot

It's said the Ottawa rules to assess which ankle injuries need an X-ray are so simple that even nurses can understand them.

This might conflict with your personal experience (it certainly does with mine) but a bunch of emergency medicine residents in the US were so convinced that the test was idiot-proof that they decided to go the extra mile and try to teach patients how to do it themselves.

To recount the Ottawa criteria for the purposes of education and revision, they go something like this: Does it hurt if you prod the lumpy bit on the outside of the ankle? Does it hurt if you prod the lumpy bit on the inside of the ankle? To make sure, prod just above the lumpy bits as well. If it isn't tender to touch and you can take four steps without falling over, then you don't need an X-ray.

The Ottawa rules test has almost 100% sensitivity - for any nurses reading, that means it won't miss anyone who actually has a fracture - and it should ensure that a GP never has to assess an injured ankle ever again.

So Ottawa negative means no X-ray required; the nurse applies a double layer of Tubigrip (while musing upon the mystery of why they don't just make the stuff twice as thick in the first place).

X-ray vision

Ottawa positive means stop pretending that GPs have X-ray vision in addition to our many other superpowers and get the patient down to A&E (No, I don't want to pop out between appointments and take a look for myself just in case).

It's reckoned that the Ottawa rules should reduce the number of X-rays ordered by around 40% so it will be interesting to see how the patients did for themselves.

But first, an instructive and predictive diversion about life in modern Britain. On a rare occasion last week when I got to enjoy breakfast in front of the TV, two teenage girls were ambushed by a camera crew as they went to collect their regular evening portions of fish and chips. If they answered a simple question they would win a trip to Iceland (the country, not the freezer centre) to learn how their meal was sourced.

The question was: 'Where does most of the cod we eat come from?'

Girl One answered: 'The ocean.' Yeah, right.

Girl Two, when told she would be crossing the North Sea, came up with: 'Oooh, will there be penguins?'

Keeping this in mind, what percentage of patients with ankle injuries who self-assessed using the supposedly infallible Ottawa criteria decided they needed an X-ray?

All of them. One hundred per cent.

Anybody who works alongside the idiot in the street, in the waiting room or on the Clapham Omnibus knows that no scheme is ever idiot-proof. It's possible to work on a protocol to make something relatively idiot-resistant but this work is done in the certain knowledge that someone, somewhere, is working equally hard to perfect a better idiot.


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