Wednesday, November 4, 2009

Annals of Wasted Resources

I performed an uneventful laparoscopic right colectomy on gentlemen a few weeks ago that went quite well. The following morning he was started on clear liquids and he was ambulated to the hallways. He looked great. His vitals were pristine. His abdominal exam was benign. He had excellent bowel sounds (I know, unreliable but I like hearing them nonetheless) and was even passing gas. His CBC, however, showed a WBC count of 15.7. Reactive white blood cell counts 18 hours after surgery are pretty much par for the course and they don't really bother us as long as the patient is doing well clinically.

When I saw him later that afternoon, he was tolerating his liquid diet and was making laps around the nursing station with his IV pole. But he asked me, "doc, why did I have to get all those needle sticks and tests today?" I had no idea what he was talking about. So I checked the chart.

The primary care doctor saw the WBC count that morning on rounds and was obviously much more concerned than I was. Eminently concerned. Freaked out would be another way of putting it. So this was what was ordered: blood cultures x 2, urinalysis and culture, CXR PA and lateral views, sputum cultures, an ID consult, and a CT of the abdomen and pelvis!!!!

I was able to get the CT scan cancelled but the rest of the orders were carried out as written. The ID consultant's note was two sentences. None of the cultures grew out anything. The CXR was negative. The patient went home two days later...

13 comments:

HudsonMD said...

A waste of money and harm to the patient. You really need to get better internists up there. What a joke!!

mark's tails said...

Well he obviously wasn't 'euboxic'. He says with sarcasm.

Anonymous said...

Had an ICU issue between, GI, Gen surgery and IM a while back. As a student I could barely keep up with the D/Cs, restarts, overrides as well as neglect of BG and cardiac. My RN was a float, and reluctant to rattle the cages as a good ICU RN should. I mumbled (to self) WTF? at my computer in the middle of it, so frustrated (almost in tears... I know, LOL) to have to reinsert the NG that was just D/C'd against my better judgement on my suffering GI bleed patient. What a bloody mess. I ended up reporting the situation to the Top Dog as he could lip read and was standing next to me, who knew?!

-SCNS

radinc said...

see, all those things are perfectly fine knee-jerk responses to an abnormal lab value.

something that an internist trained to look up lab results and order tests at the same computer before they actually go see the patients might do.

modern medicine.

later,
radinc

Tom MS2 said...

An intelligent 3rd year med student shouldn't make that mistake.

RJ said...

I'm an ID specialist and I hate these brain-stem reflex consults. Waste of time for all concerned.

Why is another doctor ordering consults and invasive tests on your patient without discussing it with you beforehand? Did you ask for a consult, or do they just routinely see all of your post-op patients?

Anonymous said...

Buckeye - Hmmm. Wonder if regional variations in care really do contribute to skyrocketing medical costs.......Only 1 explanation for this scenario. Our country has a bad, bad system. I can guarantee you that things like this happen in thousands of hospitals across the country every day. I can't imagine any other business sector where it would be considered acceptable to make decisions like that PCP did without checking with the boss running the show (you). Ridiculous.

K said...

In these instances do you bother to talk to the physician that ordered the tests to let him/her know what to do in the future?

Anonymous said...

Just wondering if a patient HAS to pay for this unnecessary testing?

Anonymous said...

Funny how some surgeons want the hospitalists to admit and discharge all the patients with surgical (not medical) issues. The same surgeons get angry if we do anything else during the admission...

Still - an abnormal lab warrants a phone call to the doc who did the operation before doing a mega-workup unless the pt is unstable.

KS said...

I have the same question as RJ: I'm assuming the patient was primarily a surgical patient, and that the medicine team was following more like a consult. How did they order all those tests without at least a passive-agressive "We recommend..." in the chart? Where I did my surgery rotation, the surgeons would have dressed down the hospitalist for even dreaming of it.

For Tom: I'm an MS3, work hard, did well on my surgery rotation...but no one ever told me that WBCs could be reactively high post-op. I don't think I saw it happen during my rotation. So I've learned something today prior to my own medicine rotation.

Bongi said...

i would be severely offended if a doctor usurped my post operative patient. this would not happen where i come from.

StorytellERdoc said...

If the family doctor was a consult on the case (which I'll assume since you performed the surgery and were probably primary admit), he should have called you with his concerns before ordering a septic workup on this patient. Nothing beats a well-timed conversation.

Thanks for a great post and great perspective.