Thursday, November 29, 2007
Efficient use of resources
Another classic example of the wasteful nature of the American way of providing medical care. An elderly lady came into the hospital last week with three days of severe RUQ pain. An ultrasound done in the ER suggested a dilated gallbladder with peri-cholecystic fluid and a positive sonographic Murphy's sign, but no gallstones. She was admitted to the medical service. A GI consult was obtained the next day. A CAT scan was ordered. Again, the imaging suggested edema around the gallbladder. She had a WBC count of 15k. Her hemoglobin was 12 (slightly anemic, technically.) So a surgical consult was obtained, right? Hardly. She was bowel prepped and underwent upper and lower endoscopy. Of course, the ubiquitous "antral gastritis" was diagnosed and she was immediately started on IV Protonix. Unfortunately, she continued to have RUQ pain (can you imagine, despite the protonix?). Cardiology was contacted but troponins and ekg's were negative. The next day a HIDA scan was obtained. This demontrated non-filling of the gallbladder up to 6 hours. At 5pm, my office received the consult for this poor lady. It hurts right here doctor, she said, pointing to under her right rib cage. The next morning she underwent a laparoscopic cholecystectomy, with severe inflammation of the gallbladder noted. She was in the hospital three days before a surgeon saw her. Multiple radiographic tests were obtained. Invasive procedures were performed. What is going on here? I'd love to see her hospital bill and tally up all the unnecessary work that was done. Multiply this case by the surprisingly numerous times similar patients are managed you'll find a gigantic sinkhole into which much of our health care dollars are lost.
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amazing! here i think we are ahead of you. certain conditions belong to surgery. even the suspicion of cholecystitis and she would be referred to us. we handle scopes too, so even if we did a gastroscopy, it would not delay management.
i know sid has posted about bleeding peptic ulcers languishing in medical wards until they have bled to irreversible shock before surgeons are involved. again, these conditions come to us from presentation. most we don't operate, but when it is needed, there is little delay.
Somehow, surgeons have ceded endoscopy to GI guys over here. If you do your own colonoscopies, you risk getting blacklisted and never seeing a colon cancer again. The troubling thing is, primary care and internal medicine increasingly look primarily to GI for ANY abdominal complaint. I can't tell you how many times I've seen a patient with an incarcerated hernia or appendicitis AFTER the GI consultant.
I agree. The workups that some obviously surgical patients get before the consult can be astounding. I must say that when I was doing my surgical hospitalist gig, since I was always there, I was able to make inroads -- getting called early for SBO and various pain entities, bleeders. It's a complex issue, made worse by the desire of many surgeons not to be involved in the diagnostic part of the equation, and by the ingrained instinct of medicos to call GI before surgery for nearly anything...
where i trained no surgeon would ever see an abdominal patient no matter what before being admitted to internal medicine and then having a gi consult. probably ercp before surgery 9/10. the er stopped calling the surgeons. the er attendings had admitting privileges to the medicine service, meaning they did not have to find anyone to agree to accept, they just assigned the patient there.
er guy happy, surgeon happy, gi guy happy, internist not so much.
do you think the er guy missed the diagnosis? and then the internist as well? and then the gi guy as well?
The above is f*ing ridiculous. OK--GI docs for whatever crazy reason are always called first in spite of obvious clinical presentation in ED. Fine. What the hell kind of GI doc worth his/her salt would not only fail to say, "We need surgery on this one," but order a CT (did things go topsy turvy such that ultrasound isn't diagnostic modality of choice for uncomplicated GB pathology?) and then based on that positive CT, scope her both ways? I'm not even touching the cardiology consult...
I will also echo a bit of what Bongi said. Here in Mexico, gastroenterology is a surgical residency, so most all operate. I had an EGD here about 3 weeks ago, and my doc was commenting to the nurse about needing to maintain schedule because there was a patient being prepped in the OR in parallel w/my study. There's a ton of overlap between a general surgeon here and a GI doc when it comes to the surgeries on the GI tract, but to what extent I'm not yet sure.
There's just so much 12-year-old turf-war mentality on top of defensive/CYA medicine that makes me more than a bit nervous about what state of things I'll find myself in a couple of years there.
This is fairly unbelievable.
As an ER guy I can echo what anonymous posted - where I trained it was such a pain the rear to get surgery to evaluate or admit anyone (Diabetes!?! Admit to medicine - we'll follow) that we would just get someone who would accept the patient. That doesn't explain this case but points out the value of a responsive service. The surgery residents where I work now are so responsive I love calling them. I call them as I walk out of the room and things start to HAPPEN!
Anon and DKV-
Good points. Past mistakes by unresponsive surgeons may certainly have contributed to this probem. But it seems simple enough to change the mentality. Get the surgeon involved early! At least call them when the patient is in the ER. The next morning the surgeon, if he's worth a damn, will realize it's a surgical issue and just take the patient on his/her service anyway.
once again, we are different here. the surgeon seldom, if ever refuses a patient. diabetic foot with dka? no physician would touch it, so i take it, treat the dka and lop off the foot/leg. cellulitis? no physician would take it, so i do. pancreatitis? no physician would take it so i do and i make the decision not to operate. then i manage it medically. we take what other people do not. as buckeye says, surgeons in south africa are 'worth a damn'
p.s, i recently discovered a difference in terminology. when we in south africa say physician, we mean specialist internal medicine guy.
See, this is why I'm glad I'm training in Canada. I'd get whacked upside the head for even suggesting the CT. Relative scarcity does tend to make you more aware of what's truly necessary...
A couple of questions:
1) It's not clear to me if cardiology was consulted DESPITE a negative EKG and trops, or if cardiology was NEEDED to perform an EKG and trops. I mean, either is inexcusable, but...
2) To the surgeons in the crowd, was ANY testing strictly necessary? Up here, we occasionally send rip-roaring appys to surgery without any imaging whatsoever, and I wonder if the same could apply with an H&P strongly suggestive of cholecystitis. I probably would've ordered the U/S and the shotgun blood panel in the ER, but now I'm second-guessing myself...
Where I work:
Acute leuks are on onc, fresh hearts....CT surg, obvious MI's going to the cath lab..cards. Every single other patient is either on medicine or has a medicine consult for "medical management" (ie. I operate then leave). A simple fact.
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