Sunday, December 16, 2007

Once again

I hate to be the sort of blogger who harps on the same damn thing over and over. But it happened again. 78 year old lady comes in Friday afternoon to ER with 24 hours of severe lower abdominal pain. Worse when she moves. She can't eat and vomited when they made her drink the barium for CT scan. WBC is 19,000. She's dehydrated. The CT scan is read as "ileus versus bowel obstruction." Admiited overnight to the medical attending on call. Saturday morning I get the consult. I browse through the chart, noting that my GI colleague has also been consulted. The WBC count makes me nervous so I see her as soon as I arrive at the hospital for rounds. I'm thinking SBO as I walk into the room, given the ER records and the CT read. Turns out, she has focal peritoneal signs in the RLQ and suprapubic area. "That makes it hurt all over", she says as I press on McBurney's point, exhibiting classic peritoneal signs. Moreover, she'd never had any abdominal surgery done. Adhesive obstruction would be highly unlikely. Hold on for a second, I say. Let me go look at that CT scan. I scroll through and damn if it doesn't look like appendicitis to me. Dilated tubular structure in the RLQ that doesn't seem to connect to anything else. Now, general surgeons who have come out of residency programs recently (like myself) may not be able to whip through a highly selective vagotomy, but we can certainly read abdominal CT scans. (Be aware of pompous statement coming up...) I can read a CT abdomen/Pelvis for certain diagnoses better than a lot of radiologists. With the new PACS machines, CT scans are readily viewable with a point and click. On call as a resident I'd sit up and look at all the scans that had been done in the ER, just for something to do to kill the tedium. By the time I was a senior resident I'd be catching appendicitis and going down to the ER before they even paged me. For this particular lady, I went downstairs and reviewed the scan with the in-house radiologist. He agreed. Appendicitis. At night, there's a "Nighthawk" system in place. All scans after hours are outsourced over the internet to some radiologist in Pakistan or India or Australia or whatever. (Are these guys even certified by an American Board? If not, aren't radiologists risking an awful lot in terms of liability just for a few hours of shut eye?)

Once again we have a case of a surgical problem undiagnosed until seen by the surgeon. In the meantime, multiple consultants are called to give an opinion. As a way to restrain myself from revisiting this topic over and over in a self-congratulatory fashion, I should probably at least try to diagnose the problem and provide a remedy. Appendicitis in the elderly is a notoriously difficult diagnosis, sometimes. You don't expect it. The literature shows that complications are higher in the elderly, primarily because of delayed presentation and delayed diagnosis. I get that. It's hard sometimes. But I think too often our fine colleagues down in the ER rely a little bit too much on a CT report. I understand it gets busy down there; you have no beds, you've got five patients waiting on reports, an acute MI who's not doing so well, charts to sign, a drunk frequent flyer causing a ruckus, a minor MVC in trauma bay and everything else. If the scan is positive call the surgeon, if not, admit to medicine. Formulaic. I'm right with you on that. But this lady presented with ABDOMINAL PAIN as her chief complaint. The CT scan suggested ileus/bowel obstruction but she'd never had surgery before. And her WBC was 19,000. Something was off. The clinical picture didn't correlate with the almighty CT report. Call the surgeon early, I guess is the answer. In this era of PA's and nurse practitioners, sometimes the ER attending won't lay hands on the patient. He/she listens to the story, agrees with proposed treatment plan and waits for test results to trickle back. It isn't good doctoring. I'm sorry.

I took her for lap appy that morning. Her appendix was gangrenous and perforated. I was able to finish it laparoscopically, wash everything out and leave a drain. Would she have perforated had I seen her 24 hours earlier? You never know. Today, she's doing great. WBC almost normal. Will probably go home Monday. No harm, no foul, I guess......


Anonymous said...

Painful, for you and the patient. From what I've read and experienced, patients don't rupture while waiting in the ED or on the floor. They either presented perforated or non-perforated. Do you agree? Thanks - surgery resident.

Anonymous said...

Hell goes round and round...

Sid Schwab said...

I'll chime in and respond to anonymous surgery resident: if a patient with a gangrenous appy spends 24 hours in the hospital before a surgery consult, that's absolutely time enough to rupture. when you think about it, the idea that they present in one state and don't move on to the other once they're admitted makes no sense. It's about the time it takes to rupture. Getting to the hospital unruptured doesn't stop the process, if there's enough of a delay in diagnosis/treatment.

Anonymous said...

Nice catch HOWEVER

re:"(Be aware of pompous statement coming up...) I can read a CT abdomen/Pelvis for certain diagnoses better than a lot of radiologists."

Let's see according to your blog:
1: You read abd CT's better than radiologist's
2: ER docs don't think
3: ID docs are worthless pieces of $hit
4: You are an internist who does surgery (yes I know schwab's words but you agreed)

Just who is the pompous one?

A little advice from an oldtimer who has been a doc since your mom was wiping your butt. We should all work together for what is best for the patient. If there was a miss by the ER doc, bring it up to him/her. Don't whine on your blog. For every story about a non surgeon missing a surgical issue, I can give you a story about a surgeon who mismanaged a nonsurgical issue or arrogantly thought he/she could manage every single thing going on with a patient and waiting WAY TOO LONG to get help. I learned a long, long time ago it's not about the you it's about the patient. You really do have some growing up (as a doc) to do.

Jeffrey Parks MD FACS said...

Anonymous- Scathing personal attack aside, your comment is appreciated.
1. Most general general surgeons read their own CT scans when looking for something like appendicitis. I catch a lot of positive CT scans that aren't initially read as positive; that's a simple fact. Radiologists don't have the benefit of "clinical correlation". My hands have been on the belly of the patient who just went through the scanner. Don't deduce from this that I think I'm a better radiologist in general.
2. I never implied ID docs are worthless. The problem is the rampant consult system we have in place at American hospitals. Nurse calls the primary doc; informs him of a fever; ID is consulted. It's absurd. Every UTI/pneumonia/phlebitis gets an ID consult. I think that's embarassing. ID is a subspecialty that is NOT worthless; I just think we overdo it on getting them involved.
3. ER docs are under a lot of pressure to get patients out of the ER. The evaluation system at my hospital places inordinate amount of prestige on "number of patients seen and processed" during an ER physician's shift. The quicker the attending gets the patient to ICU/floor/home, the better his performance evaluation. That's a systemic problem. And I always talk to ER guys about patients I've operated on. I find they are usually very interested to find out what happened to patients they saw the previous night.
4. Pedantic and patronizing lines like "don't whine" and "since your mom was wiping your butt" and educating me on pomposity are a little demeaning to yourself, and perhaps betray an immaturity, even at your esteemed age, that could be rectified. We all need to grow up, myself included. It's a long process. If you don't like the blog, don't read it. Go find someone else to rip.

Anonymous said...

"since your mom was wiping your butt" and educating me on pomposity are a little demeaning to yourself, and perhaps betray an immaturity, even at your esteemed age.."

Interesting. I am not the one on a blog ripping every other specialty (except my own), you are. Your backtracking aside, your blog has a long history of minimizing and downplaying other specialties (ID happens to be the most obvious though you appear to slam many specialties) An example of one of your plethora of anti-ID comments "It's a specialty that certainly has a place; HIV, Hepatitis, unusual organisms, non-Western hemispherean illnesses. But now every local hospital has these huge ID groups that are glorified culture-checkers". Wrong. I have seen ID come in with such simple things as a drug fever that the surgeons had been flailing away at for days (one of many examples). Yes, ID consults may be over-ordered (like every specialty, just how many abd pains have you seen without a basic w/u to determine if it was surgical, probably more than you can count). That is a discussion for the person ordering the consult. We all spend years in a given specialty learning that craft. Statements like "surgeons are internist's who do surgery" is the epitome of arrogance and frankly a lack of knowledge of that specialty. A basic example. In all the years of surgical consults I did as an internist (I subspecialize now, NOT ID) I never, ever saw the basic w/u for hyponatremia (serum, urine osmols, urine NA, etc). Never, not once. The typical response is to use fluids, doesn't correct then fluid restrict, then maybe call medicine. No w/u. I am not necessarily expecting a hyponatremia w/u by a surgeon, but please don't say you are an "internist who does surgery". I learned a long time ago that as docs we all have a place. That we were all trained for our place. That we should work together. That we should keep the negative, flippant, arrogant, self-serving comments to ourselves unless there are clear concerns of patient safety/management by a doc. It is not about us after all. You are right that "growing up" is a life long process in medicine. That stated, I often find the "fresh grads" the least understanding of the purpose of other specialties and the ones who are most likely to "not know what they don't know".
Good luck on your career.

Jeffrey Parks MD FACS said...

I challenge you find where I've ever made the statement "a surgeon is an internist who operates." You won't find it because I never said it. Your aggressive and patronizing tone toward me actually is a little worrisome. Do I need to be worried about my family's safety?

Diagnostic errors are made all the time in medicine, in all specialties. That's part of the "practice" of medicine. I have complications; all surgeons do. My beef is with the casual flippancy American doctors bring to practice. I don't think enough thinking is done. You now, actual doctoring. Why should the old lady from the nursing home who comes into the hospital with mental status changes, fever, and a urinalysis that shows over 100WBC/hpf get infectious disease and neurology consults? Too much of medicine is practiced as a spread the blame, load the boat sort of fashion and it's just wasteful and inefficient. The cases I've presented on this blog highlight this and in many instances, patient care was indeed hindered by systemic inefficiency. The collaborative nature of medicine that you allude to is certainly something to strive for. But when it takes six doctors to determine that someone needs their gallbladder taken out, I think you have a problem. Why does health care consume such a large portion of our budget? Doctors practice in fear; needless MRI's and CT scans, ridiculous consults, it all adds up. But at some point I think you have to look in the mirror and decide that you're going to actually BE A DOCTOR. Guess what, I know how to work up hyponatremia. I manage post-operative diabetes. I know what to do in the first hour if a patient has an acute MI. If you find that "arrogant", then I don't know what to say to you. My philosophy is, as the patient's surgeon, I'm responsible for their care. It's my patient. I'm sorry you find that reprehensible. But I know when I get older, and I need medical attention, I'm going to want the guy who's aggressive, smart and willing to take responsibility for everything I need. If that doctor happens to be a "fresh grad" so be it. Again, if the ideas presented on this blog are so repellent to you, please fell free to, oh I don't know, maybe stop reading it. I'm a surgeon; I have to get the last word, so everytime you post, it forces me to write a long, rambling post in return. And that's a pain in my ass. Happy new year.