July 27th, 2009 by Dr. Val Jones in True Stories
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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.
April 28th, 2009 by Dr. Val Jones in True Stories
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Doctor: Mr. Smith, your urine test is positive for cocaine.
Mr. Smith: [Blank Stare]
Doctor: Have you been snorting cocaine recently?
Mr. Smith: No.
Doctor: Then why is there cocaine in your urine?
Mr. Smith: Maybe your nurse put it in there.
Doctor: If my nurse had cocaine, I don’t think she’d put it in your urine.
***
Bonus tip for pain management specialists: cocaine’s half-life in the urine is 2-4 days. “Random” urine drug testing on Mondays offers a higher yield than other days of the business week because most patients abuse illicit drugs on weekends>>weekdays.
October 13th, 2008 by Dr. Val Jones in Expert Interviews
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My friend Dr. Joe Scherger and I enjoyed a sunny Sunday brunch at a garden eatery in DC. Unfortunately for the neighboring restaurant-goers, we engaged in a very loud and animated conversation about vasectomies. Joe is a family physician and men’s health expert who has recently become aware of “post vasectomy pain syndrome” through an online group that he leads. I noticed two men nearby crossing their legs reflexively and pretending not to be eavesdropping.
Apparently, as many as 10-15% of men may experience a prolonged period of testicular pain after undergoing a vasectomy. As common a complication as this is, Joe believes that very few men are sufficiently warned about it during the informed consent process. The pain may be caused by swelling (once the vas deferens is cut there is no exit point for newly generated sperm) or inflammation. In some cases, the body forms “anti-sperm” antibodies and attacks the sperm generating tissues in the testes. In other cases, small nerves in the area are damaged and heal poorly (causing neuromas).
So if you or your loved one is considering a vasectomy, it’s important to learn all the facts first. You may want to stop by Joe’s online group to ask a question as well.
July 28th, 2008 by Dr. Val Jones in Expert Interviews, Health Policy
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I had the chance to interview Drs. Carmona, Satcher, and Novello about the current state of America’s war on cancer. I’ll post each conversation in a separate blog entry. This post explores Dr. Novello’s views on creating a healthcare navigation system for patients with cancer.
Dr. Val: How are cancer patients navigating the system currently?
Dr. Novello: They are relying primarily on their oncologists to help them navigate. But even though oncologists want to help their patients as much as possible, the reality is that they are taking care of thousands of patients at a time and simply don’t have the bandwidth to assist with the level of detail necessary.
Cancer is extremely complicated and patient care is not just about diagnosis, staging, and treatment. It also includes tests for genetic markers, coordination of genetic counseling, finding appropriate clinical trials for the patients to participate in, locating a continuity of care supervisor, rehabilitation services, scheduling chemotherapy, radiation, and surgical treatments.
Cancer doesn’t happen in a vacuum – patients also have other medical conditions that need to be managed along with the cancer diagnosis. In addition, one must create a comprehensive follow up plan for survivors, including scheduling of surveillance tests to identify possible recurrences. If a cure is not an option, then palliative care and hospice services must be coordinated. In addition to that, patients must create a living will, designate someone to have power of attorney over their care, and prepare for the legal aspects of their passing. This is why a diagnosis of cancer can be overwhelming to most people, and they are in desperate need of a structured program to help them navigate the complexities and to ensure that the ball is not dropped anywhere along the way.
Dr. Val: What’s the best way to help cancer patients more successfully navigate the healthcare system?
Dr. Novello: We need to create a simple, comprehensive, and accurate way to offer guidance to all Americans with cancer so that they can get the best care possible. You know how some hospitals have painted lines on the floor to help people to navigate from A to B in the building? Well we need this kind of line system for cancer care.
Ellen Stoval at the National Coalition for Cancer Survivorship, Lance Armstrong and his Foundation, members of the Institute of Medicine and the Centers for Disease Control and Prevention, and members of the President’s Cancer Plan at the National Cancer Institute, have formed a coalition to delineate the features of an ideal cancer patient navigator system. Senators Kennedy and Hutchison are preparing a bill for congress – it would ensure that Medicare covers a cancer patient navigator service. It remains to be seen who will build the service, and how it will be distributed.
Dr. Val: What are the key elements of a cancer patient navigator system?
Dr. Novello: The coalition is unanimous in their opinion that the navigator must provide culturally sensitive, clear information in the native language of the patient. A cancer patient navigator should include assistance with:
Diagnosis: Every patient needs to know the name and stage of the cancer that they have.
Treatment: The treatment plan (including chemotherapy, radiation, and/or surgery) that is recommended for them.
Scheduling: A schedule of all their appointments.
Pain Management: A comprehensive plan for pain management so that the patient is not denied access to narcotics if needed.
Psychosocial Services: Access to psychosocial services to assist with coping strategies for depression and family and marriage counseling.
Insurance Assistance: a plan for financing the cost of treatment – specifically an insurance advocate who can help the patient understand and maximize their insurance benefits, and if they’re uninsured, a way to get coverage for the care they need.
Peer Support: A list of support groups that can assist the patient with their emotional needs.
We need everyone to support this upcoming bill so that all cancer patients will have access to a navigation tool that will help them get the care they need in a timely fashion. Successful navigation of this healthcare system can mean the difference between life and death for cancer patients.
Dr. Novello is the Vice President for Women and Children’s Health Policy at Florida Hospital in Orlando, Florida.
*See the National Call to Action on Cancer Prevention and Survivorship*This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
March 12th, 2008 by Dr. Val Jones in True Stories
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Every physician has a few traumatic patient stories forever etched in their minds. My friend Dr. Rob recently blogged about the sad case of a little boy with an ear infection – his bulging red eardrum suggested a common problem requiring antibiotics. Little did anyone know that the bacteria behind the drum would get into his spinal fluid, causing meningitis and rapid death. Another emergency medicine physician tells the story of an elderly woman whose aorta dissected right in front of the medical team, with barely enough time for the trauma surgeon to save her life.
One of my surprising moments occurred when I was an ER resident. A middle aged woman (we’ll call her Lizzy) was sent to the ER in the middle of the afternoon after a near-fainting episode in a pain management clinic. She was fairly well known to the more senior residents and staff (she was a chronic pain patient on multiple medications who came to the ER for frequent generalized pain work ups and rescue doses of her meds). So since this lady had cried wolf a few too many times, she was assigned to me – the newbie.
I had no pre-conceived notions about Lizzy, and hadn’t experienced her exaggerated and benign abdominal pain claims in the past. She was lucid, with a smoker’s cough and mildly disheveled, short hair with dark roots and blond tips. She explained that she had been at her usual pain management appointment when she got up from the waiting room chair to register and almost blacked out. She described feeling lightheaded, and needing to sit back down immediately. The clinic staff called our ER to transfer her for an evaluation.
Lizzy seemed fairly cheerful and unconcerned about her near fainting – as if swooning bought her a free ride to the ER to see her “other doctors.” But still, something didn’t seem right to me about her. She was light skinned, but not pink enough. Her blood pressure was low-normal. She had no particular pain anywhere, though on the levels of narcotics she was taking it would be a miracle if she could feel any pain at all. I decided to watch her, take serial vitals, and order a CBC and Chem 7 to see if there might be any signs of dehydration or anemia.
The second set of vitals showed a slightly lower blood pressure and a slightly higher pulse. She sat on the stretcher, watching the TV without any particular sense of urgency. Since it was an unusually slow afternoon, I got the chance to ask for more details of her medical history. Lizzy described her normal daily activities at the assisted living center, and how she had attended a party where she’d had a bit too much to drink and had fallen on a chair a couple of days ago. She said it hurt at first in her left upper quadrant, but it felt only slightly sore now.
Her CBC came back with a lowish hematocrit, and a third blood pressure reading was trending lower yet. I really wasn’t sure what was going on, but I was getting nervous. I presented the case to my attending (who knew the patient very well) and suggested that we get an abdominal CT to rule out internal bleeding.
He rolled his eyes and sneered at me. “Do you know how many CTs this woman has had already?”
“Um, no…” I winced.
“She gets one every freaking time she’s in here, and it’s always non-specific. Inexperienced residents like you are wasting hospital resources on drug seekers!”
“But she does have some anemia, low blood pressure, and a history of abdominal trauma…” I mumbled.
“She’s always slightly anemic, with low blood pressure – what would YOUR blood pressure be on high dose oxycontin?”
“But she looks pale and she almost fainted…” I tried to continue my argument.
“Alright, Jones… I’m going to let you order the CT as a learning experience for you. This is a teaching hospital, and I guess that means that we can irradiate patients at will. Go ahead… we’ll see what it shows.”
By this time I was really questioning myself. I’d gotten in an argument with one of our attendings who knew this patient intimately and had years of medical experience beyond my own. If I was wrong about her, he’d make me pay for the rest of the year – and tell all the other residents about my poor clinical judgment and wasted hospital resources. I was very nervous, but I just had to follow my instinct.
I sent the woman to the CT scanner with a reassuring pat on the shoulder. She winked at me and disappeared into the radiology suite.
Ten minutes later I was paged by the radiologist, his voice was tense – “Your patient has a splenic laceration, you’d better call in the trauma surgeons. She’s fading fast…”
Before I could put the phone down I heard the trauma team being paged overhead and some surgeons emerged from behind a curtain and started running to the CT scanner, almost knocking me off my feet in the hallway.
As it turns out, the trauma team was able to save Lizzy by removing her spleen. She spent several days in the hospital receiving blood transfusions and recovering from the operation. My attending never mentioned the incident again, though I never forgot Lizzy’s near-death experience. Maybe it was a blessing that I was a “newbie” when I met Lizzy – my lack of knowledge of her usual behavior allowed me to view her with a fresh eye, and take her complaints seriously. It’s really hard to hit that reset button with every “frequent flier” in the ER – but sometimes it can save a life.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
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.
