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The Importance of the Physical Exam, Part 3

I was working in the ER late one night when I was asked to see an elderly woman with the chief complaint of “I almost fainted.” This complaint carries with it one of the broadest differential diagnoses known to man. What could be the cause of a near fainting episode in an elderly woman? It could be anything from dehydration, to an irregular heart beat, to anemia, to malnutrition, to a urinary tract infection or pneumonia. Pretty much anything could make one swoon when you come to think of it.

And so I met the lady, perched atop a stretcher in one of the ER bays. She was chipper and friendly with a shock of curly white hair. She was sitting up, conversing comfortably with no pain or any bodily complaints whatsoever. She was absolutely charming, taking the time to notice my own disheveled condition and inquiring as to when I’d had my last meal.

Her blood pressure was a little bit low, but she had no fever, or heart rate abnormalities. She was not over or underweight, she was well-groomed and alert. I really doubted that there was anything wrong with the woman, frankly, and was kind of assuming that she had stood up too quickly and had a vasovagal episode.

But out of habit I began my physical exam, from head to toe – methodically looking for abnormalities of the head, eyes, ears, nose, throat, cranial nerves, chest, lungs, back, skin, range of motion of arms, strength, sensation, heart sounds, and then the abdomen. As I placed my cold hand nonchalantly on her belly, my arm instinctively jerked away almost before my cerebral cortex was able to interpret the input. Oh my gosh, there was a pulsatile abdominal mass, clear as the nose on her face!

I was barely able to compose myself and asked her to excuse me. I bolted straight for the attending’s desk, and white as a sheet with wide eyes I stammered: “the lady in bed 3 has a pulsatile abdominal mass!”

The attending stood up immediately and followed me to the lady’s room and confirmed my diagnosis. She had a dissecting abdominal aortic aneurysm. We called the trauma surgery team and she was taken to the OR minutes later. The dear lady survived the surgery and was discharged home in her usual state of pleasantness. I’ll never forget that physical exam finding, and how taking the time to place my hand on her belly was all that was needed to save her life. If I had gone with my suspicion prior to the exam (that she was fine but maybe had a UTI) I may have wasted the precious few minutes she had (before her artery ruptured) on getting a urine sample!

***

For other surprising physical exam findings, check out part 1 and part 2.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

When What Can Go Wrong, Does Go Wrong

My father-in-law just had his gallbladder removed. There was a small complication with the surgery (due to pus leakage from the gallbladder) and a laparoscopic procedure needed to become an open surgery. He did fine and is recovering nicely. I’m very glad that his surgeons did what they needed to do to get that infected organ out of his body safely.

However, his very minor “complication” reminded me of a gallbladder horror story that I once heard about from a surgeon friend of mine. I have changed many details of this story to protect the privacy of the patient (whom I’ve never met), but I think it’s important to talk about the event, especially in light of the recent surgical errors being discussed in the blogosphere.

A young man had suffered from gallstone “attacks” and was scheduled for a very routine laparoscopic cholecystectomy. It was the end of the day, and the surgeon scheduled to do the procedure had been working a 24 hour shift, and was quite tired and irritable. He wanted to do the procedure as quickly as possible and get home to dinner and an early night’s rest. The nursing staff remained quiet as he fumed and sputtered, preparing the patient with a betadine scrub and letting them know that he wanted to set a new record for speed of gallbladder removal.

The small incisions were made and some trocars were inserted so that the belly could be inflated and a camera and instruments inserted through the holes. The surgeon went to work quickly dissecting and preparing to remove the offending organ. In his haste, however, one of the instruments fell out of the skin incision. Enraged, he asked for a new one and began inserting a trocar blindly into the skin incision without guiding it with the camera. He had some difficulty getting it in, and began applying more and more pressure to puncture its way through to the middle of the abdomen. Exhausted, he jabbed it back inside with a final twist, inserted the instrument and then picked up the camera to continue the procedure.

Confusion gave way to terror as the internal camera showed the belly filling up rapidly with arterial blood. The surgeon had punctured the abdominal aorta during the trocar reinsertion. This was a surgical emergency. Ashamed of his mistake he decided to try to handle this himself, opening the belly wide to cross clamp the aorta and repair it without the patient needing to know about his near brush with death. Unfortunately, the repair took far longer than the surgeon expected, and blood flow to the legs was compromised for several hours (causing internal clots). Many units of blood were ordered for transfusion, nearly draining the blood bank of its reserves.

Tragically, although the young man did survive the surgery, he required an eventual double amputation of his legs. And all this after what he thought would be a simple gallbladder removal.

This is a sobering example of how serious any surgery can be, and why it’s so important for every procedure to be handled with the utmost patience and care. Many people have told me that surgeons don’t need to have a “good personality” because they mostly deal with anesthetized patients, but I think that this is a shallow view. A surgeon’s character is uniquely tied to his or her performance, and if they have a propensity towards a short fuse, it could result in tragic errors like this one. If you are considering surgery, you should feel comfortable with your surgeon’s style and personality. Don’t be afraid to get a second opinion or seek out a different surgeon if something doesn’t seem right. Your life may depend on it.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Making Sense of the ACCORD Study: Doctors Should Treat People, Not Numbers

Much to the dismay of scientists, policy makers, and health care administrators, good medical decision making is not always black and white. I understand and sympathize with our desire to distill complex disease management issues into specific, easily measured variables. But unfortunately, the human body is exceedingly complex, and willfully resists reductionist thinking.

The recent ACCORD trial (which was designed to quantify the value of aggressive glucose management in a diabetic population) actually demonstrated a higher mortality rate in the intensive treatment group. What? That’s right, people were more likely to die if they had been randomized to the group that used all means necessary to keep blood sugars in a near normal range.

Now, this does NOT mean that it’s a bad thing for diabetics to keep tight control of their blood sugars, but it MAY mean that if they have to take high doses of multiple drugs to get them to that aggressive goal, the negative drug side effects may collectively outweigh their benefits.

I spoke with Dr. Zachary Bloomgarden, a renowned diabetes expert, to discuss his interpretation of the trial results. Here is a snippet from our interview:

My feeling is that this study shows that there is an art to medicine, and that patients can’t be managed via cookbook methods to treat their disease. If a person can control their blood sugar to an A1c of 6.0 without using too many medications, then that might be a good goal for him or her, but if you have to take high doses of several pills to get to that same goal (and therefore experience all the unfavorable additional side effects from taking them like weight gain, fluid retention, and potential arrhythmias) then it might not be appropriate in that case.

Ultimately, it takes a personalized approach by an experienced physician to determine the best treatment plan for an individual patient. One size doesn’t fit all – that’s part of my
take away from this study.  We still
certainly want all people with diabetes to do as well as they can with blood
sugar as well as blood pressure, cholesterol, and the myriad other markers of
control of the disease.

And so my plea is that in our race to ensure “quality care for all” in this country, we take a moment to consider that real quality may not be about getting every patient to the same blood test target, but to get every patient to a primary care physician who can apply evidence based recommendations in a personally relevant way. Cookbook medicine is no substitute for good clinical judgment. Let’s invest in our primary care base, and make it financially viable for them to spend the time necessary to ensure that their patients are on individually appropriate therapeutic plans. I hope our next President will appreciate the critical role of primary care in a healthy medical system.

Addendum: a like-minded fellow blogger weighs in on the study

.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Lack of "Continuity of Care" Can Kill

For various reasons, our healthcare system has become very fragmented. Physicians are under financial incentives to do tests and procedures (rather than counsel patients), to become specialists instead of generalists, and to diagnose and treat large volumes of people at 5-10 minute intervals. Gone are the days when primary care physicians took care of 3 generations of family members, watching them grow, understanding their mental and physical health intimately, and helping them to get the right care at the right time. Doctors are rarely part of the family anymore, they’re robots on a really fast treadmill, doling out test results and prescribing procedures based on population based protocols deemed maximally efficient at treating disease at minimal cost.

Does this transition from trusted friend to mechanical puppet matter in terms of health outcomes? The argument is that using lab tests and evidence-based protocols substantially improve health – which is why government initiatives like Pay for Performance are pressuring physicians to treat you from a common diagnostic cookbook. But when we lose the human element in medicine, the long term relationships (aka “continuity of care”), we may misdiagnose people and prescribe inappropriate treatments. Working at lightning speed adds fuel to this dangerous fire. Perhaps a true life example will crystallize my arguments:

Frannie Miller was a thin 86 year old woman living independently with her husband. Although she was slightly forgetful, she managed to do all the cooking, cleaning, and general home upkeep. One day she slipped on the stairs entering her house and fell on the cement. She fractured two of her vertebrae and spent some time in the hospital to manage her pain. Upon discharge she decided to stay with her son’s family since she wasn’t able to return to her usual independent regimen. Her son, dutiful as he was, carefully recorded all of the medications that she had in her pill bottles, and set up a daily schedule to administer them to her. What her son didn’t realize, however, is that Frannie had been prescribed these medications by three different physicians operating independently of one another.

Frannie had mild heart failure with a tendency to retain some fluid around her ankles, so she was prescribed a low dose diuretic by a certain physician. Of course, Frannie didn’t think she really needed the medicine, and never took it. On a follow up visit with another physician, Frannie was noted to have the same mild ankle swelling, and (assuming that she was taking her medicine as directed) the new doctor believed that she needed a higher dose of the medicine and prescribed her a new bottle (which of course, Frannie never took). About 6 months later at a follow up appointment, a third physician met Fannie and further increased her diuretic dose.

So when Frannie arrived in a weakened state at her son’s house, and he decided to give her all the prescribed medications, she received a massive dose of diuretics for the first time. Several days after convalescing at home, Frannie became delirious (from severe dehydration) and not knowing why her mental status had changed, her son took her to the nearest hospital.

Of course, no one knew Frannie at the hospital and had no records or knowledge of her health history or her baseline mental status. She was admitted to a very busy general medicine floor where (after being examined only very briefly) she was believed to have advanced senile dementia and hospice care was recommended for her. Her son was told that she probably wouldn’t live beyond a few weeks and that he should take her home to die. A visiting nurse service was set up and Frannie was discharged home.

How is it that a fully functional 86 year old woman was sentenced to death? It was because of a lack of continuity of care (a shared online medical record could have helped) with doctors moving so quickly that no one took the time to sort out her real problem. Are diuretics appropriate treatment for heart failure? Yes. Did any one doctor violate Pay for Performance rules for heart failure? No. Did the population based protocols work for Frannie? Heck no.

There are so many Frannies out there in our healthcare system today. How can we measure the harm done to patients by the fragmentation of care? Who will collect that data and show the collateral damage of the death of primary care?

This particular cloud – thankfully – has a silver lining. A physician friend of Frannie’s son happened to inquire about her health. The son explained that she was dying, and the physician rightly pointed out that there was no real medical reason for her to be that ill. The friend asked to see her medication list, and knowing that Frannie weighed about 80 pounds was shocked to see a daily dose of 120mg of lasix. Slowly the diuretic SNAFU became clear and the family friend asked that Frannie be immediately rehydrated. She perked up like a wilted flower and returned to her usual state of health within days. Frannie was cured.

I believe that we must find a way to get shared medical records online for all Americans. Having scads of frantic specialists operating independent of one another for the wellbeing of the same patient, yet without being able to share a common record, is endangering an untold number of lives. Not having continuity of care – a primary care physician for each American – is also endangering lives and reducing quality of care. If we could get these two fixes in place, I believe we’d have revolutionized this country’s healthcare system.

What do you think?This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

Good Cholesterol (HDL) Is More Important Than You Think

Heart disease is the number one killer of Americans, and high cholesterol levels are a primary contributor to heart disease. But the cholesterol story is a bit complicated – some of it is damaging to blood vessels (Low Density Lipoproteins or LDL is considered “bad” cholesterol) and some of it is restorative (High Density Lipoproteins or HDL is “good” cholesterol). Most medications are aimed at lowering the “bad” cholesterol, and this strategy has been very helpful in reducing heart disease and atherosclerosis. But what about raising the good cholesterol as part of a heart healthy strategy?

A new study in the New England Journal of Medicine suggests that having low levels of HDL can put people at risk for heart disease and heart attacks, even if the LDL is well controlled.  This is the first study to show that low LDL does not erase heart disease risk if the individual’s HDL is also low.  In fact, each increase of 1 mg in HDL cholesterol is associated with a decrease of 2 to 3% in the risk of future coronary heart disease.  So lowering LDL with statins (if lifestyle measures fail) is only half the battle for those who also have low HDL.So how do you increase your HDL levels?The most effective medicine for raising HDL is a type of Vitamin B called niacin.  Taken in the quantities required to have an effect on HDL, though, there are usually unpleasant side effects: flushing (redness or warmth of the face), itching, stomach upset, mild dizziness, and headache.

Perhaps the best way to increase HDL is to lose weight and exercise regularly.? In fact, the list of HDL-raising “to do’s” reads like a healthy living manual:

1.  Avoid trans fats

2. Drink alcohol in moderation

3.  Add fiber to your diet

4.  Use monounsaturated fats like olive oil where possible

5. Stop smoking

6. Lose weight

7. Engage in regular aerobic exercise

So next time you see your doctor, make sure you review your cholesterol levels, and discuss some strategies to get your levels of HDL and LDL in the optimal zones for a healthy heart.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.

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