April 2nd, 2008 by Dr. Val Jones in True Stories
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I’m at a medical conference in Houston this week (picking up some CME credits) and between lectures I’ve had some interesting conversations with my peers. Here’s my favorite story:
A patient underwent a total hip replacement surgery, had a normal post-operative course, was transferred for inpatient rehabilitation, progressed well and was discharged home. Several months later the patient decided to sue the hospital, claiming that he was sent home with a dislocated hip. The hospital couldn’t prove that the patient’s hip was not dislocated at the time of discharge because no x-ray was taken on that day. Of course, the only reason an x-ray would have been taken was if there were a strong suspicion of a fracture or dislocation (x-rays are not normally repeated on the day of discharge).
The hospital was found liable and will settle out of court for an undisclosed (but very large) amount.
My guess is that this case will cause:
1. The hospital to take unnecessary x-rays of all total hip patients on the day of discharge from now to eternity.
2. More dishonest patients to file frivolous law suits.
3. The local med/mal attorney population to spread the word about a new source of income.
4. Further cutbacks in the hospital’s charitable care due to funding deficits.
5. Someone with a hip replacement to buy a new Ferrari.
Sigh.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
March 23rd, 2008 by Dr. Val Jones in True Stories
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I just learned a valuable lesson.
A friend of mine described some fluid build up in her knee, made worse by exercise. She said she had seen an orthopedist who recommended surgery… and she wondered what I thought. Based on her description, I assumed that she had an acute knee effusion – potentially from some recent exercise-induced ligament or meniscal damage.
My friend said that she was concerned about having surgery, and that she was planning to have an MRI first. I must admit that I was a little bit confused as to why surgery was recommended so quickly, without having the MRI results to confirm the cause of the effusion (and that surgical correction was warranted). My knee jerk response was to question the clinical judgment of the orthopedist, and to wonder if he was too “surgery happy” and was leading my friend away from conservative measures (of which I am a great fan).
Several weeks passed, and I finally met my friend in person for a quick look at her knee (she was still waiting for the MRI). Guess what? She did NOT have a knee joint effusion at all. What she had was an almond-sized ganglion cyst on the side of her knee.
I felt pretty silly. Of course the orthopedist recommended surgery (a tiny procedure under local anesthetic) without the MRI. He was indeed offering the appropriate treatment.
Sometimes a picture’s worth 1000 words. And sometimes the physical exam can make the diagnosis – no other studies needed.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
March 21st, 2008 by Dr. Val Jones in Uncategorized
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This week I was honored to be featured as the first post in the line up at Polite Dissent’s Grand Rounds. Over the past couple of weeks Revolution Health’s bloggers have been doing their part to contribute to health knowledge. Here’s my round up of the best of their recent posts:
Health tips
Spring break is coming up for millions of children and teens. Dr. Stacy Stryer has some health tips for sun and water safety.
Stretching is an important healing technique for some injuries and conditions. Dr. Jim Herndon explains what we know about the use and value of stretching exercises.
Does an affair mean your marriage is over? Mira Kirshenbaum has some suggestions for healing after infidelity, and a group to help you do it.
Some people feel regret after prostate cancer surgery. Dr. David Penson offers some empathy and advice.
What’s new in prostate cancer treatment? Dr. Mike Glode give a short synopsis.
Meditation might decrease your sleep requirements. Dr. Steve Poceta reviews this claim.
Did you know?
Men hate to apologize. Relationship expert Mira Kirshenbaum has some ideas as to why that might be.
Teen scientists are contributing to colon cancer research. Dr. Heinz-Josef Lenz discusses what his daughter and a Junior Nobel Science Award-winning teen have in common.
Toenail fungus is very common in the elderly. Dr. Joe Scherger explains why this is so, and why it’s so difficult to treat.
Overweight menopausal women may suffer more severe hot flashes. Dr. Vivian Dickerson explains why.
An anti-snoring shirt has been developed to help people remain on their sides while asleep. Dr. Steve Poceta explains how sleep position is related to snoring.
Human growth hormone doesn’t actually strengthen your muscles, it just makes you retain water. Dr. Jim Herndon reviews the latest research.
There’s a new clinical trial designed for women with metastatic colon cancer. Dr. Heinz-Josef Lenz explains what the scientists are hoping to learn from the research study.
Baby-naming is an art. Dr. Stacy Stryer discusses the history of finding just the right name for your child.
Patient advocate Robin Morris discusses her opinion of Larry King’s recent autism-focused show.
How should a doctor share bad news with a patient? Neurologist Larry Leavitt explains.
***
Happy Easter weekend everyone!
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
March 19th, 2008 by Dr. Val Jones in True Stories
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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.
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.
