July 8th, 2009 by Dr. Val Jones in Health Policy, True Stories
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My mother-in-law just had a CT scan of her head in the Emergency Department of her local hospital. My husband called me to ask if I could “talk to her about her headache.”
Severe headaches in the elderly are indeed worrisome, and I wondered if she had fallen recently – if she might have a bleed in her brain requiring immediate surgery. Of course, she’d need a CT scan to rule that out… I was prepared for the worst. But what I learned by simply talking to Mrs. Zlotkus was unexpectedly revealing – not only about her diagnosis but about our healthcare system in general.
As it turns out, Mrs. Zlotkus had been having severe headaches for about 3 months. She was taking Vicodin daily to “take the edge off.” When I asked her about the location of the pain, she said that it was “just on one side of my head, from the top of my neck to the top of my head.” I asked her if the pain sometimes traveled to the other side, or if it involved her eye. “Never,” was her quick response. She also told me that she’d been seeing a physical therapist for 2.5 months for neck stretching exercises.
Mrs. Zlotkus told me her CT scan was negative, and that her blood tests didn’t show any “temporary arthritis.” (That’s temporal arteritis, I presume.)
“Well,” I said, “There’s only one thing left that I can think of that will give you a headache in the exact area you’re describing – and that’s shingles. Did you notice any scabs or painful bumps on your scalp when the headaches first started?”
“Why, yes!” Said Mrs. Zlotkus. “About 3 months ago I noticed some very painful, crusty scabs on my scalp. I thought for sure it was because my hairdresser used extra strong chemicals on my hair. I scolded her for it. She told me to put tea tree oil on it.”
Oh, boy. There it was – a diagnosis as plain as the nose on her face.
“Um… Well did you tell the ER docs about the scabs?”
“No. They never asked me about it and I didn’t see what my hairdresser’s chemical burn had to do with my severe headaches.”
My mother-in-law’s work up (ER visit, CT scan, several doctor visits, pain medicines), misdiagnosis (neck muscle stiffness), and mistreatment (physical therapy) for shingles probably cost upwards of $10,000. Worse than that, she did not get anti-viral treatment early enough in her outbreak to prevent a long-lasting pain syndrome (called post-herpetic neuralgia). Now that she has this shingles-related headache, it’s very hard to treat. And taking lots of acetaminophen-rich medications (Vicodin) is the last thing her liver needs right now.
So how did the healthcare system fail Mrs. Zlotkus? In my opinion, this is a great example of the “failure of synthesis” that Evan Falchuk discusses on his See First blog. Somehow, the physicians involved in Mrs. Zlotkus’ care didn’t take the time to think about her symptoms, to ask the right questions, and to put all the puzzle pieces together. Instead, they just ruled out the potential emergency issues (a stroke/hemorrhage, or temporal arteritis) and gave her a follow up appointment with a neurologist (who couldn’t fit her in their schedule for 2 months). They didn’t take a full history – they just dumped her in the most likely diagnostic category (neck stiffness) and let some other specialist follow up. Shameful.
I’ve described more egregious examples of hasty medical care on this blog – consider the case of an elderly woman (the mother of a friend of mine) who was misdiagnosed with “end stage dementia” when she really had acute delirium from an overdose of diuretics… Or the case of my girlfriend who was mistaken in the ER for a drug seeker when she was suffering from a kidney stone.
Sometimes I feel as if I have to keep an eye on all my friends and family before they set foot in a hospital, ER, or doctor’s office. I’m afraid that those providing their care will be so rushed and thoughtless that my loved ones will wind up with a huge bill, the wrong diagnosis, and perhaps even a near-death experience. I am seriously afraid for them.
The bottom line is that we have to stop rewarding providers for volume over quality. We have to value the history and physical exam beyond the CT scan and lab tests. We have to give doctors the chance to think about their patients – rather than turn up the speed dial on the clinical treadmills as a means to reduce costs.
My mother-in-law just spent $10,000 of our tax dollars on a diagnosis that could be made in 5 minutes of thoughtful questioning over the telephone. Multiply that cost by the number of other Medicare beneficiaries who are suffering similar misdiagnoses in this country and we’re talking serious money.
Under-thinking leads to over-testing. Has the CBO taken that into consideration in its scoring of various reform plans? I don’t think so. To me, this is yet another reason why we need physicians at the table in healthcare reform – we see the real cost drivers that others might not think of – even if some of us are too busy to diagnose shingles correctly!
June 26th, 2009 by scanman in Better Health Network, True Stories
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…
I was called to do an urgent bedside ultrasound scan of the abdomen for a trauma victim.
The patient was a young man of twenty-four who had been involved in a road traffic accident (RTA = MVA in US medical terminology). He had been brought – without any kind of basic life support – after sustaining a major trauma at a village about two hours away. The intensivist in the ICU told me that he was in severe hypovolemic shock on admission with a GCS of 4. Preliminary examination and radiographs had shown a comminuted fracture of the right femur (thigh bone) with a large hematoma and some facial bone fractures. After initial assessment and resuscitation in the casualty, a CT scan was done. He had a fracture in the frontal bone and a few small contusions in the brain, that raised the possibility of Diffuse Axonal Injury, nothing that could explain a GCS of 4 though. The assumption was that it was all due to extensive blood loss and hypovolemia. He was shifted straight to the ICU after the CT scan and I was called to do an ultrasound scan to check for hemoperitoneum (ie, abdominal injury and blood loss).
The scan was normal. As I was doing the scan, the intensivist was busy trying to put in a Subclavian central line. He secured the line just as I finished my scan, which incidentally was normal. As I was stepping away from the bed, the patient had a cardiac arrest, as evidenced by sudden bradycardia on the monitor. I moved out of the way as the intensivist, orthopaedic surgeon and ICU nurses went through a full resuscitation protocol. After a while, even I realized that it seemed like a futile exercise.
I was not particularly busy, so I peeped into to the Cardiac ICU next door as there seemed to be some commotion there. My cardiologist colleague, a normally friendly soul was peering intently at a very fast heart rhythm on a monitor over the bed of a young girl of about six or seven. There were a couple of nurses injecting something slowly into an intravenous cannula in the kid’s forearm. In passing, I noted that the kid was very calm and seemed very interested in what the nurse was doing. I stepped close to my friend and asked what was up. He turned, gave me a quick nervous smile and said he was trying to revert an SVT (supraventricular tachycardia, a very nasty fast heart rhythm). Honestly, I had never seen an SVT in someone so young, so I asked him what was the history. He told me the kid was brought by her mother to his outpatient clinic a short while ago because she complained of palpitations (I forgot the exact description used by the kid, but it was quite descriptive). My friend said he was sure it was an SVT after a quick examination in the clinic, so he rushed the kid upstairs to the Cardiac ICU, connected her to a monitor, confirmed the diagnosis and had ordered Adenosine IV stat for reversal. He maintained his intent survey of the monitor as he recounted the story and the nurse continued her slow IV injection. At one particular point when the line on the monitor became particularly squiggly, he shouted, “STOP!” and the nurse stopped injecting.
…
It was almost magical.
…
The squiggles became a recognizable cardiac rhythm, albeit very fast – about 160 to 170 beats per minute. My friend called out to one of the superfluous nursing attendants and asked them to get the kid’s mother inside. A very anxious young lady who had obviously been weeping was led in. My friend showed her the monitor and explained to her that the nasty rhythm had been made to behave itself or something to that effect and told her that the kid was out of any imminent danger.
Happy with the positive outcome, I strolled out to be confronted by a wailing family, including two young girls, maybe a year or two older than the calm kid inside, who had just been told that their older brother who fell off his motorbike was dead.
It was past my work hours. I went out and had a drink and reflected.
Such is life.
…
*This blog post was originally published at scan man's notes*
June 22nd, 2009 by Medgadget in Uncategorized
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SonoSite just released their SonoRemote for controlling the company’s M-Turbo and S Series ultrasounds during interventional procedures like joint injections or central line placements. In addition to traditional style buttons, the remote control features voice recognition and can be programmed to understand commands in any language. So now you can hold the probe in one hand and the syringe in the other, and not have to fiddle with reaching over to the unit to take snapshots or change parameters.
Voice or touch activated
Programmable to your voice and language
Adjust system controls from a radius of 10 meters
No need to break the sterile field
Drop-tested to 3 feet
Works with M-Turbo® and S Series™
Press release: SonoSite Begins Customer Shipments Of Ultrasound Remote Control
Product page: SonoRemote
Flashbacks: M-Turbo™: New Portable Ultrasound from SonoSite ; SonoSite S-ICU™ Ultrasound Tool; S-Nerve™ from SonoSite; The SonoSite® MicroMaxx™; Titan
*This blog post was originally published at Medgadget*
June 17th, 2009 by scanman in Better Health Network, Opinion
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Abortion and the intense debate about it in an otherwise enlightened (?) country was the topic of two of my earliest posts in this blog (this post and this one). I posted again when it looked like the debate was going to start in India. Thankfully, it died a natural death.
Those of you who follow me on twitter know that abortion has been on my mind following the sickening murder of Dr. Tiller. For the record, I didn’t even know that there existed such a doctor as he till I chanced upon news of his death. I refrained from writing anything here as I figured I had stated my views already.
Then I saw this post in my friend Dr. Val’s blog.
The abortion “issue” is such a hot topic that I have never written about it on this blog until today. I hope I won’t regret that decision but I felt it was appropriate to respond to this medical student’s essay – and the ~560+ comments that follow it – as a physician who has witnessed (but never performed) about 100 abortions. Let me explain.
Read the entire post at Better Health: A Third-Year Medical Student Discusses Her Views On Abortion In The Washington Post.
Also read the medical student Rozalyn Farmer Love’s post, My Choice, in the Washington Post.
I’m a third-year medical student at the University of Alabama at Birmingham. I plan to become an obstetrician-gynecologist. I dream of delivering healthy babies, working with families and supporting midwifery. But as part of my practice, I also envision providing abortions to women who need them. …
I agree that ending an unwanted pregnancy is a tragedy. When I advocate for reproductive rights, for choice, I don’t claim that abortion is morally acceptable. I think that it’s a very private, intensely personal decision. But I was stunned when one of my professors, a pathologist and a Planned Parenthood supporter, told me that decades ago, entire wings of the university’s hospital were filled with women dying from infections caused by botched abortions. It’s clear that women who don’t want to be pregnant won’t be deterred by limited access to providers or to clinics. And I believe that it’s immoral to let them die rather than provide them with safe, competent care.
The lines that affected me the most were…
I plan to choose a residency program that provides further training — a place where I won’t worry that asking to be taught to perform an abortion could somehow limit my future options. At the start of medical school, I was very careful about how I presented my pro-choice views to the faculty for fear that I could jeopardize my grades or hurt my chances for recommendations or of being accepted into a program run by any of the professors. This experience of treading lightly is unique to medical students in more conservative parts of the country, where opposition to abortion is widespread…
I was equally moved by these lines from Val’s post…
I initiated rapid sequence intubation with the assistance of the anesthesiologist, and then moved to get the ultrasound machine to visualize the uterus and its contents. Much to my discomfort the fetus was fairly large – and was moving around normally, even sucking its thumb at one point. I asked the Ob/Gyn resident why the fetus was being aborted since it didn’t appear to have any structural abnormalities. She responded that the mother simply didn’t want to have the baby, and had wrestled with the idea of abortion for a long time before she made her final decision. The rest of the procedure is a bit of a blur – with details too graphic to describe here. But suffice it to say that the resident performing the dilatation and curettage had a fairly difficult time removing the fetus through the cervix, and had to resort to eliminating it in smaller parts, rather than a whole. It was very sad and it took a long time to make sure that the uterus was fully evacuated. I decided that I couldn’t watch another one of these procedures.
All I can say to Val is: Do not visit any ObGyn procedure room or OT if/when you visit India.
I did not set out to write this to hand out that gratuitous bit of advice to Val. I wanted to highlight something else that she had written that caught my attention and raised some doubts.
In my opinion women should have the right to choose to have an abortion, but I’d hope that they also consider their right to choose to give their baby up for adoption as well. Some believe that an abortion is “easier” than giving up a baby for adoption – but I’m not so sure that’s the case from an emotional perspective.
I want Val and all those who share similar views re. adoption as an alternative to abortion to read this moving essay by Judy Brown in which she says When Abortion Was a Crime, I Would Have Sought One. Read the entire essay and pay particular attention to the two paragraphs at the end…
There are approximately 500,000 children in the foster care at any time in the United State — many of those children are adoptable, but will not be adopted — why don’t “pro-life” advocates step forward to adopt them now? Do they want the forced return to warehouse orphanages for still more unwanted children? Do they want women sent to prison for seeking an abortion, and doctors also jailed, when we already have a shortage of doctors in this country? And nurses jailed, when we have a shortage of nurses in this country? How much damage and destruction of life will they support to force the rest of us to subscribe to their “religous” views? I’ve never heard a so-called “pro-life” advocate answer those questions honestly. Making abortion illegal will not stop abortions, it will just stop safe abortions, as is the reality in the few civilized countries in which abortion isn’t legal, but their abortion wards are full to bursting with maimed women, and whose morgues overflow with dead women.
I agree with Val’s concluding paragraph that Rozalyn, the third year medical student may change her mind after witnessing or performing a few procedures.
Even in a country where abortion is a non-issue, I believe there are many medical professionals who are troubled by late trimester abortions and abortions-on-demand. I am one such. But the sad reality is that we are the minority here. I feel particularly sad because occasionally in my professional role as a diagnostic radiologist I am the cause of some of these wrenching cases of late trimester abortions. Some of them I can agree with, though they could have been avoided by earlier diagnosis and decision-making, like an anencephaly being diagnosed at 35 weeks gestation. But most are not that morally or ethically clear cut.
*This blog post was originally published at scan man's notes*
June 10th, 2009 by Medgadget in Better Health Network
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Continuing this week’s streak of medical fashion coverage, we found these custom sonogram cufflinks that are advertised as a perfect present for an expecting father. It would probably be out of taste to present a cardiac patient with cufflinks featuring echocardiography scans of his mitral regurgitation or aortic insufficiency from endocarditis.
Product page: Sonogram Photo Cufflinks
(hat tip: BoingBoing)
*This blog post was originally published at Medgadget*
