WNL: We Never Looked

Machiavelli's Laboratory is a free ebook that I published on April 13, 2010. It is a satiric discourse on scientific ethics, from the perspective of an unethical scientist. Please don't take any of the advice and opinions in the book (or the excerpts featured in this blog) seriously.

If you should ever have the opportunity to leaf through the pages of a medical chart, you're apt to come across the abbreviation: WNL. WNL is intended to indicate that an observation or measurement was "Within normal limits". More often than not, WNL really means "We never looked." A busy doctor or nurse will often find it inconvenient to measure respirations (inspirations per minute), blood pressure, pulse rate, and temperature, the so-called vital signs, on every patient, on every round. If you look at a patient's chart, and you find that every entry for the vital signs is entered as: "Respirations: 12, Blood pressure: 120/80, pulse 72, temperature 98.6," you can be certain that the values were obtained without the aid of a measuring device. Nobody in a hospital has perfectly normal vital signs, without variation, on every set of measurements. This is an example of WNL.

The introduction of "WNL" provided medical staff with yet another time-saving innovation. No longer must caregivers feel the need to invent a set of fictitious numbers. By applying WNL, the chart will indicate that the vital signs, whatever they might be, were within normal limits.

Hospitals provide staff with numerous opportunities to seem professional, on paper, without really doing much of anything. In 1994, Betsy Lehman, an award-winning health columnist for The Boston Globe, was treated for breast cancer at the world-renowned
Dana Farber Cancer Institute. While there, she received four times the intended dose of the cancer drug, Cytoxan, over four consecutive days, and died. At Dana Farber, treatment protocols are always reviewed by pharmacists and caregivers. None of the people who checked-off their approvals had actually looked at the dosage and perceived that it was wrong. After the wrong dosage was given, and the patient reacted by vomiting blood admixed with sheets of intestinal lining cells, the staff failed to take immediate action. At the time, it seemed that Ms. Lehman's reaction was WNL ("Within normal limits"), but it was much closer to WNL ("We neer looked").

[Corman C, Mondi L, Park A. The disturbing case of the cure that killed the patient. Time. Monday, Apr. 03, 1995]

Tragic as the Dana Farber incident may be, it pales in significance to the scale of carelessness exhibited at Harlem Hospital in New York.

[Hartocollis A. Heart Tests at Hospital Went Unread. The New York Times. May 25, 2010]

Echocardiograms are very specialized ultrasound tests that measure the functionality of the heart muscle and the heart valves. They're not cheap, costing up to about $500. Doctors only order the test when they are concerned that the patient might have a heart problem. At Harlem Hospital, about 4,000 echocardiograms were ordered, but the doctors never read the reports. The tests were performed, and the patients were billed, but the results were not delivered to the chart or to the doctors who ordered the tests.

Now, you might think that a doctor who ordered an electrocardiogram would insist on seeing the results. But no. The backlog of unreported results was found during a routine review of records by staff affiliated with the hospital's corporation (not by the doctors who treated the patients).

Each year at Harlem hospital, about 2,500 electrochardiograms are ordered. This means that the 4,000 backlogged cases occurred over a period of nearly two years. None of the doctors who ordered those tests seemed to notice that they never got the results. WNL in action!


- © 2010 Jules Berman