July 28th, 2009 by Bongi in Better Health Network, True Stories
Tags: Drowning, Good Die Young, Live Forever, South Africa, Surgery, Swimming
2 Comments »
Ask almost any surgeon and he will tell you your chances of surviving a catastrophe are inversely proportional to your usefulness to society. This sentiment is expressed in different ways by different surgeons but the basic message is the same. If two people come in with exactly the same injuries and one is a teacher who spends his extra time in community upliftment projects and the other is an armed robber, the armed robber will sail through treatment and be back on the streets in no time, but the teacher will slowly waste away in ICU and finally die. Unfortunately it seems to be true.
There was a super clever cardiologist friend of mine who speculated as to why this was the case. He basically divided people into two groups, those with over active immune systems and those with just the basic immune system. The first group would tend to be allergic to everything and be over protected by their mothers. They would tend to grow up in a protected environment devoting their time to inside activities (safe from the dangers of the outside world, including grass and pollen and dog hairs and the like) reading and bettering themselves. The latter group would be immunologically free to run around like wild things doing whatever they liked.
He then extrapolated this to the likelihood that the first group possibly had a higher chance of developing SIRS (systemic inflammatory response syndrome) after major trauma and it was in fact their own immunity’s overreaction that finally brought them down. Amazingly enough this theory is based on logical scientific thought.
Like all surgeons I too tend to think that the good guy will probably die and the bad guy will survive. I have seen it too often. But unlike my boffin cardiology friend I think it is just some sort of evil cosmic reverse karma that is out to destroy all good people in this world. This makes much more sense to me than actually trying to understand immunology. And that is why I try to do at least one bad thing a day so that if something does befall me I at least have a chance of surviving. But there are always limits.
A few years ago our hospital organised a weekend away for all the doctors and their families. It was at a really nice lodge here in the Lowveld and truth be told, it was great. The days were pretty much spent lounging around the pool. That is of course if you didn’t play golf. I don’t play golf.
Anyway, there I was producing vitamin D for all I was worth when I glanced over at the pool. One of the other doctors had a small boy of about 4 years old that had been running around all day like a mad thing. But at that moment, as I looked at him leaning over the edge of the pool he toppled in. I was about 10 meters away so I first looked to see who was closer that would respond. No one moved. No one had seen him fall in except me.
Then everything went into slow motion. I could see that he could clearly not swim. His eyes were wide open as his arms an legs flayed about helplessly not bringing his head any closer to the surface. He was clearly in trouble. Then a strange thought went through my mind based on my above mentioned philosophy.
“If I leave him, that is bad enough that I will probably live forever.”
Who actually wants to live forever?
So I rushed over and pulled the kid out.
His mother seemed pleased.
*This blog post was originally published at other things amanzi*
July 27th, 2009 by Dr. Val Jones in True Stories
Tags: Anesthesiology, Dermatology, Medical Home, Nerve Block, Pain Management, Second Opinion, shingles, Varicella Zoster, Wasted Resources
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Regular readers of Better Health will recall my personal frustration that my mother-in-law received 2 months of physical therapy, a head CT, and extensive blood testing in response to a shingles outbreak that I was able to diagnose easily over the phone.
The misdiagnosis that resulted in chronic post-herpetic neuralgia and a $10,000 waste of resources, has continued to vex me. After Mrs. Zlotkus and I realized what was going on, I outlined for her the usual treatment regimen for shingles pain – explaining that most people needed a fairly high dose of the nerve pain medicine before they experience any relief at all, and to make sure her doctor gave her an adequate dose before deciding whether or not it worked.
And you can guess what happened next.
Mrs. Zlotkus was seen by a young and inexperienced neurologist who insisted on giving her a very tiny dose of the nerve medicine (it has an excellent safety profile even at very high doses). Of course, it didn’t help. She was given 100mg twice a day (where shingles sufferers often need as much as 1800mg/day) with instructions to return in a few weeks. The doctor also told her that she “couldn’t be sure the pain was due to shingles since she hadn’t seen the original rash.”
That’s like an ER physician saying to a trauma victim that they can’t be sure of the cause of the injuries because they didn’t witness the car accident.
At that point I instructed her to find an experienced pain management specialist who’d know how to titrate her medication appropriately – and who might even be able to do a nerve block to get her some immediate pain relief.
Luckily, Mrs. Zlotkus “knew somebody who knew somebody” and was able to make an appointment the next day with a senior anesthesiologist experienced in nerve blocks. The pain management physician knew just what to do, administered the nerve block, increased her medication dose, and sent her on her way. She experienced immediate relief of her symptoms and felt like a new woman.
If Mrs. Zlotkus had gone directly to the anesthesiologist in the first place, she might have saved herself months of agony and a $10,000+ bill to Medicare. (Better yet she would have gone to her PCP when she first noticed scabs on her scalp and he would have prescribed an anti-viral medicine that could have aborted the entire pain syndrome.) But how was she to know which provider was right for her? How could she know that her neurologist was prescribing her the wrong dose of pain medication, and that a nerve block might solve all of this nicely. Without the correct diagnosis, a cascade of wasted resources and personal suffering ensued. Without me nudging her in the right treatment direction – perhaps she’d still be doing neck stretching exercises in physical therapy?
I am a fan of the “medical home” concept as described by the AAFP and wonder if it could have made a difference in Mrs. Zlotkus’ care:
“In this new model, the traditional doctor’s office is transformed into the central point for Americans to organize and coordinate their health care, based on their needs and priorities. At its core is an ongoing partnership between each person and a specially trained primary care physician. This new model provides modern conveniences, like e-mail communication and same-day appointments; quality ratings and pricing information; and secure online tools to help consumers manage their health information, review the latest medical findings and make informed decisions.
Consumers receive reminders about necessary appointments and screenings, as well as other support to help them and their families manage chronic conditions such as diabetes or heart disease. The primary care physician helps each person assemble a team when he or she needs specialists and other health care providers such as nutritionists and physical trainers. The consumer decides who is on his or her team, and the primary care physician makes sure they are working together to meet all of the patient’s needs in an integrated, ‘whole person’ fashion.”
In summary, there’s a lot of waste in our medical system caused by a lack of coordination of care, hasty diagnoses, and defensive medicine. Even the most common diagnoses (like shingles) can end up setting off a chain reaction of over testing, incorrect treatment and personal suffering. We need an “OnStar” system for healthcare – a way to help patients navigate their way to the right care at the right time. The medical home model is as good a GPS system as any… so long as the primary care physician at the center of the coordination of care is not so rushed that she can’t do her job properly. And that’s the secret to making the medical home work – giving the doctor enough time to unravel the problems at hand and figure out the best next steps in care. If we get this right, we can probably say goodbye to CT scans for shingles.
July 26th, 2009 by scanman in Better Health Network, True Stories
Tags: Cheating, Delayed, Dictation, Radiology, Surgery
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via The Trial of a WhiteCoat – Part 14.
The radiologist that read the film had a habit of going to the surgeons the following day and asking them what they had found. He would open up a blank report so that it looked as if it was dictated at the time of the exam, but would then hold the reports as “preliminary” and finalize them after dictating in the results of the surgeries. That way it looked like he had picked up on all these small findings before anyone else knew about them. He was a decent radiologist, so no one seemed to mind that he was adding all these findings after the fact. Now it burned me.
I’m offended.
No.
That’s too light.
I’m pissed off as hell.
I believe the Americans call this kind of thing “Monday morning quarterbacking.”
Whatever you might call it, this is cheating in my book.
I don’t know why they let that radiologist get away with this kind of behaviour.
Moreover, I can’t believe that anyone would take the man’s reports seriously, leave alone the surgeons that he got information from. If by chance I was a surgeon in that hospital, I would intentionally throw him red herrings.
In case you haven’t been following Whitecoat’s account of his malpractice case, see previous posts of his epic saga here. Far better than reading any crime/legal thriller, cheap or otherwise. John Grisham could take lessons from Whitecoat.
*This blog post was originally published at scan man's notes*
July 26th, 2009 by KerriSparling in Better Health Network, True Stories
Tags: Antibiotics, Clinics, Dexcom, Diabetes, Dumb Doctor, Infectious Disease, Primary Care, Type 1 Diabetes, Urinary Tract Infection, UTI
1 Comment »
Earlier this week, I had a bit of a medical issue. Painful urination, high blood sugars, and the constant need to pee. (Ladies, I know you already know what’s up.) Urinary tract infection looming large. I was livid, because it was the day before I was scheduled to travel for this week’s business.
I haven’t got time for the pain, so I called my primary care physician, Dr. CT. “Hi Nurse of Dr. CT! It’s Kerri Sparling. Listen, I’m pretty sure I either have a kidney stone or a urinary tract infection, and I need to rule it out before I leave for a week-long business trip.”
Dr. CT was on jury duty. Damnit. So I had to call a local walk-in clinic, instead.
The clinic was a hole in the wall. Part of a strip mall structure. My confidence wasn’t high, but my blood sugars were and my whole body was screaming for attention, so I knew I had to follow through.
The receptionist was very nice. The nurse was even nicer. They took my blood pressure (110/74), my temperature (98.8) and a urine sample (ew). 
I should have known from the moment the sample cup was given to me that it wasn’t going to be a fun visit. The very kind nurse handed me this —>
That is not a urine sample cup. That’s like a party cup that you use for lemonade on a hot summer day. Not for pee. Oh God.
And then the doctor came in. For the sake of anonymity, we’ll call him Dr. Idiot.
“Hi. I’m Dr. Idiot.”
“Hi, I’m Kerri.”
“Kerri, I see you are here for pain when urinating. Are you urinating frequently? You see, you are spilling a significant amount of urine. I believe we may have found the source of your troubles.”
He closed his file, proud of himself.
“Dr. Idiot? On my chart there I wrote that I have type 1 diabetes. I know my blood sugar is elevated right now, which sucks but at least it’s not a surprise. But that’s not why I’m here. I actually suspect that …”
He cut me off.
“I think we need to address this first problem. You are aware of your diabetes, you say? How many times a month do you check your sugar? You know, with the glucose machine and the finger pricker?”
If I wore bifocals, it’s at this point that I would have slid them down my nose and given him a hard, Sam Eagle-type stare.
“I test about 12 – 15 times a day. But the real reason …”
“You mean a month,” he corrected me.
“No, I mean a day. I have type 1 diabetes. I wear a continuous glucose sensor. And also an insulin pump. I’m very aware of my condition, and I’m also very aware that it’s slipping out of control today because of this other issue, the pain issue. Can we talk about that?”
He looked at my chart again. “So you don’t use a meter?”
“Sir, I use a meter. And a machine that reads the glucose levels of my interstitial fluid. This is in addition to my insulin pump. I don’t mean to be rude but …”
Now he gave me a hard look. “Why the interstitial fluid? Why not the blood directly? I mean, you could have more precise readings with the blood.” He picked up my Dexcom from the chair next to me and pressed a few buttons to light up the screen. (Mind you, he did not have permission to touch it, but I’m again not saying anything.)
“You mean like a pick line? I don’t know. I’m sorry. Ask them?”
“Yes, but it would make much more sense and …”
I just about lost it.
“I’m sorry. I didn’t come here to talk about that. I want to talk about the issue I’m here for. Which is not diabetes. Or your ambitions to know more about CGMs. Please can we address what I’m here for?”
“The sugar in your urine.” With finality, he says this.
“NO. The fact that I think I have a UTI or a kidney stone. Please. Help. Me?”
I kid you not – we went ’round and ’round about this for another ten minutes. He didn’t believe me that I was at least sort of familiar with diabetes. His ignorance included, but wasn’t limited to, the following statements:
- “High sugar causes frequent urination. Maybe that’s why you are peeing often?” (Not because I was drinking a liter of water per hour to flush my system? Nooo, couldn’t be that.)
- “Did you have weight loss surgery?”
- “Grape juice also causes high blood sugar.”
- “That thing should really be pulling blood samples. Pointless otherwise.” (Meaning my Dexcom.)
- “The urinalysis won’t be back until Friday, and in the meantime you should start on a regimen of insulin immediately.”
- And also: “I didn’t peg you for a pink girl.” (Are. You. Serious??)
The end result, after an escalating argument that involved me yelling, “Stop. Talking about my diabetes and PLEASE focus why I’m here!” was a prescription for Macrobid that I could elect to take if my symptoms didn’t alleviate, and the instructions to call back on Friday for official lab results.
“Thank you. Really. Can I go now?”
He at least had the decency to look ashamed.
I’ve had some wonderful doctors over the last 30 years, and my health is better for it. But this guy? Complete disappointment.
*This blog post was originally published at Six Until Me.*
July 24th, 2009 by Shadowfax in Better Health Network, True Stories
Tags: Emergency Medicine, Lab Coat, Light, Pen, Pockets, Stethoscope, White Coat
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Long, long ago, when I was a medical student, we joked that you could tell how senior a physician was by how much junk was in their lab coat pockets. As students, we tended to carry around big bags full of every medical gadget we could think of, plus a few reference texts. The attendings were slim and graceful in their long white coats with empty pockets.
When I became an intern and moved into the hospital full-time, all that crap became just too much to lug around. I ditched the bag, and my short white coat (with interior pockets, thank god) became loaded down with tons of stuff: reflex hammers, pocket reference guides, photocopied research papers for reading, patient lists, a procedure log, a PDA with epocrates, a bit of a snack maybe, and more. The coat weighed at least ten pounds fully loaded. As a junior resident, I pared it down to the few references and gadgets I actually used frequently, and the coat got a lot lighter. With each succeeding year I have lightened the load somewhat, down to the absolute essentials. I shed the white coat years and years ago. Now the only things I bring with me to the hospital are:
Three items. It’s very liberating. Of course, I have epocrates and more on every computer workstation, so the references are there in the ER for me, but still, it’s something of a victory over inanimate junk and my own packrat tendencies that I can go to work with only three things in my pockets.
The downside is that if I happen to forget any one of these three sacred totems, it totally ruins my whole day.
*This blog post was originally published at Movin' Meat*
Ask almost any surgeon and he will tell you your chances of surviving a catastrophe are inversely proportional to your usefulness to society. This sentiment is expressed in different ways by different surgeons but the basic message is the same. If two people come in with exactly the same injuries and one is a teacher who spends his extra time in community upliftment projects and the other is an armed robber, the armed robber will sail through treatment and be back on the streets in no time, but the teacher will slowly waste away in ICU and finally die. Unfortunately it seems to be true.
