Boreal B[l]og

A 28 year-old woman comes to the hospital with significant left-sided abdominal pain, and the imaging study is read as showing a small left-sided inflammatory process felt to be diverticulitis, despite no diverticulae being seen.  No comment was made about the appendix. Diverticulitis with perforation in the large bowel may occur in the young, but it is an older person’s disease.  As a former clinician, I would be bothered about that diagnosis.

But, four days later, the patient was better.  A repeat study was performed just to be certain nothing was awry.

Something was.

The patient now had an abscess in her left side of the abdomen, and there was inflammation throughout the peritoneum.  This time, a different radiologist looked at the scan in a different plane.  There are 3 anatomical planes for viewing: sagittal, coronal, and  transverse.  In the coronal plane, it was clear that the appendix had ruptured.  In the sagittal plane, where the prior reading had been made, the appendix wasn’t visible.  Radiologists don’t always look at all the planes.   They get paid by numbers of cases reviewed, just like most physicians, and there is a lot of pressure to take care of many patients.  Before you say this is wrong, remember that many people complain of emergency department waits.  If a radiologist takes a lot of time to read a scan, people wait.

But the appendix is on the right side of the abdomen.  What gives?

I have a book from my late father-in-law called “The Early Diagnosis of the Acute Abdomen,” by Sir Zachary Cope, the 8th edition, written in 1940.  It should be required reading for every medical student.  The appendix is attached to the cecum, and the cecum is on one side of the iliocecal valve, leading from the ilium to the large bowel.  The first radiological report did not mention the cecum.  This was a major oversight.  Unless the cecum is identified, the appendix cannot be identified, either.  If those two cannot be seen, appendicitis as a cause of the problem cannot be excluded.  In a young person with significant abdominal pain, appendicitis is always a consideration until proven otherwise.  When I was a shipboard doctor, I had read Cope’s book 5 times, because diagnosing appendicitis meant either an operation on board (I did two, one by myself) or an expensive Mede-vac, with a helicopter landing on the small flight deck of a ship.  I’ve done that many times, and it requires skilled pilots.

The cecum can be not only in the right side of the abdomen, but in the middle or other parts.  The appendix, therefore, can be anywhere in the lower abdomen, the pelvis, in the middle, and even in the right upper abdomen, mimicking gall bladder disease, should it be retrocecal, or behind the cecum.  The appendix can irritate the bladder, mimicking urinary infection.  If the appendix is pelvic, ruptures, and forms an abscess, the abscess will move up the left side of the abdomen, the path of least resistance, exactly what happened here.  Two of the best medical adages are: first, uncommon manifestations of common disorders are more likely to occur than common manifestations of uncommon disorders; second, when you hear hoofbeats, think horses, not zebras.

The woman will be operated upon and should survive, but she will have extensive scarring in her abdomen, which will likely lead to future bowel obstructions and multiple operations.  If she has children and needs a C-section, it will be a very difficult procedure, since bowel may adhere to the uterus and perforate during surgery.  She would have had future problems had she been diagnosed promptly, but not nearly to the extent that she is likely to have now.

It just isn’t the fault of the radiologist, however.  Where were the clinicians?  Why would a clinician accept diverticulitis in a 28 year-old with no other diverticula being visible? Why was there no statement why this could not be appendicitis?  Such a statement would show that the clinician had at least thought of the diagnosis.

I made a lot of mistakes in practice, but any time I was bothered by a diagnosis, I either kept looking at the patient or asked a colleague what he or she thought.  I also wrote a provisional diagnosis on my reports for X-Rays, not just “headache” or “abdominal pain.”  I wrote, headache, slight left sided weakness, glioma a possibility,” or “abdominal pain, left-sided, high white count.”  The radiologists loved having the information I provided them, and I got better reports, too.

I recently learned from a pathologist the astounding fact that with the advent of imaging procedures that supposedly allow us to look inside the body without surgery, that autopsies, the few that are done, show NO CHANGES, repeat, NO CHANGES in the pathology that was MISSED by the clinician and the radiologist during life.  This is scary.  It means that our assumption that we know what is going on with a patient on the basis of an imaging test may not be correct

This is the second time I have discussed a major problem with appendicitis in a young person.  The first patient died.  This person walled off the abscess, which the body used to do fairly successfully, in the days before good diagnosis and good surgery.  My grandfather had unoperated appendicitis and survived.  It can happen, and it did in 1940.

I would like to think in 2012 that we might be a little better.  I’m not really so sure we are.  And that bothers me as much as a diagnosis that doesn’t make sense.  It makes me worry and think, “What else could be going on?”

There is one other adage we would do well to remember, the most basic rule of all:  “Listen to the patient.  She is trying to tell you what is wrong with her.”

I needed a prescription refill for a medicine I have taken for 3 years.  My prior physician allowed calls to be made by the pharmacy to refill the prescription, so I didn’t have to go to his office to get one.  Unfortunately, he left practice to do concierge medicine.  I didn’t wish to pay $1500 annually for 24/7 access to a physician.  For years, I thought that went with the territory, along with not charging for the thousands of telephone calls I returned.  I can’t tell you how important it is as a patient to get a physician’s call.  I can’t put a dollar value on it, other than to say a big “Thank You” to the physicians who have called me back.  That has no dollar value, either, but I think they appreciate it.

Physician #2 left practice to become a hospitalist, because he was unable to afford continuing the practice he was in.  Physician #3 required a visit to refill this particular prescription, which is neither addicting nor dangerous.

We don’t have standardization in medicine for those things that need to be standard.  We disparage it as “cookie cutter” medicine, when in fact, cookie cutter approaches ensure good cookies.  “People are different,” I hear. No, we really aren’t as different as many would like to think.  Most men have similar anatomy; most women have similar anatomy.  Our physiology is the same, and our bodies react to insults in predictable ways.  That is why we study pathology.  Surgeons take out gall bladders the same way, and as a neurologist, I had a standard history and “cookie cutter” neurological exam.  I seldom forgot anything important.  What does differ is how we personally react to disease, and in a short office visit, time spent on that is virtually nil. I practiced for 20 years, so I know the difficulty in trying to diagnose, treat, and understand the patient’s reaction to an illness in a short office visit.

I drove to the physician’s office and asked for a prescription for 2 pills twice a day, 120 pills in all, with 5 refills.  I had my request written on a piece of paper.  I had to come back 2 days later to pick up the prescription.  The office could have sent it, but that requires something to be done by somebody else.  If I do it myself, it is more likely to get done right. Prescriptions can be lost and not sent.  It is only 45 minutes round trip, so it is nothing important, only my time.  When I returned, two days later, I was given my prescription, written for 1 pill twice a day, not 2, as I had asked for, but 120 pills in all, with 3 refills, not the 5 I had asked for.  I could have asked for the prescription to be written the way I had written it down, but the 120 pills a month was right, so I took it to the pharmacy, explaining carefully that this was a new prescription from a new doctor, who would be henceforth refilling future prescriptions.

The pharmacy normally calls me when my prescription is ready.  They didn’t call.

So, I walked to the pharmacy, 10 minutes fortunately, and was told that I could only get 60 pills, not 120, because the prescription was written for 1 pill twice a day. They said they couldn’t reach my doctor, but they mistakenly had called my previous one, who was no longer in practice, despite my having told them I had a new doctor, whose name and telephone number was on the prescription.

The pharmacy said they would call the doctor’s office.  I left the pharmacy empty-handed, because if I got 60 pills, I would have to explain to the insurance company why I needed a new prescription, should I again want 120 pills, which I do. The next day, the pharmacy said nobody picked up the phone.  I drove to the office, handwritten note again, and asked for another prescription, either to be called in or given to me to pick up.  While there, I asked if they had been called.  They said no, and they answer, so I am not clear whom the pharmacy was calling.

The following day, I got the prescription filled, a week late.  What would have happened if I did not have extra medication?  What would happen if I were 85, no medical background, not thinking clearly, because I was 85 and in ill-health, and on several medications?  I might end up in the hospital, which would be a five figure cost, because of breakdown of a really simple system.

I ask:  what is so difficult about writing and filling a prescription correctly?   Frankly, insurance companies should be trying to fix bad systems in medicine, which would save them far more money, than worry why a 63 year-old is taking 120 pills of Drug X every month, the same amount, and is doing just fine.  I am unable to refill a week in advance, should I go out of town during the time the refill is “allowed.”

No, insurance companies should fix bad systems, like ensuring antibiotics are given in a certain time window before elective surgery, which would save them far more money, as would standardizing the antibiotic. When I was medical director, we met the time window only a quarter of the time, and we had a post-op infection rate 4 times higher than Salt Lake City.  That amounted to about 20 extra infections a year, or a few hundred thousand dollars.  Those are all facts.  We had one doctor use a very expensive antibiotic for his patients, increasing the possibility of resistance, and I was unable to get the Surgery Department to deal with it.  We also had 3 wrong-side surgeries: on the head, knee, and bowel.  The first one was not communicated to the internist following the patient, who resigned from the case, he was so angry.  Bad systems cause trouble.

My pharmacy experience is is one reason why so many of us are so angry about medical care today.  It doesn’t work properly.  Systems are broken, and it costs money and time, and makes people frustrated and angry.  While time is supposedly money, it isn’t to me.  It has uncountable worth.  Unnecessary anger and frustration are uncountable expenses.  Being uncountable does detract from their importance, a fact lost upon many today.

Thirteen years ago, I bet my career on becoming one who taught people how to fix bad medical systems, and I lost.  Here is how medical errors have affected my small family:

My mother’s final illness began with a fainting spell.  She was taken to the hospital where we were told her CT head scan was normal. Five months later, 1500 miles from home, her rapidly progressive dementia led to a fall, breaking her hip, and she was delirious after surgery.  I had to fly to Portland, put my abulic (more than dementia, destruction of personality) mother, recovering from a broken hip, on a plane, and bring her home.  At the same hospital, we discovered she had refused the initial CT scan, and nobody had told us.  Worse, the attending physician later changed the note on the chart (the note that said “CT normal”), which is illegal.  Three more days (uncountable cost) were spent in flying to Portland (countable), to bring my parents’ car home.  My mother died soon after, so the error probably didn’t matter much, although the way she died still bothers me (uncountable cost).

My oldest brother’s meningioma was misdiagnosed until he went blind in one eye.  He is a professional photographer, so this is a significant issue (uncountable cost).   I am hoping the meningioma doesn’t grow further and kill him, because he refused surgery.  That might not have been a bad idea, given the location of the meningioma and given how complex medical procedures are.  After all, if we can’t deal with prescriptions properly, what is the probability of a successful operation?  Are there data? Or is it just anecdotal?

During my father’s final illness, he had low protein and edema so extensive that it literally wept through the skin on his legs.  Despite that, his nurses said he had heart failure.  I tried to explain to the head nurse that a lab test to measure protein was overdue,  that I was not the enemy, only wanting to ensure my father got the care he needed (uncountable cost, except for the lab test).  The response from the head nurse was “Let doctor take care of it.”

In my language, doctor takes a definite article.  For an unknown reason, omitting it annoys me.

I had a significant mistake made in my own medical care which led to 2 months of the worst misery I have ever experienced.  The medication for this condition is the one I have been trying to get at the pharmacy.

We argue about insurance reform, but we waste countable billions on bad systems;  suboptimal care, unnecessary deaths, and the uncountable cost of unnecessary frustration.  A family member of mine may need chest surgery and stay overnight in the ICU.  I will sleep there.  Many doctors would agree with my decision.  If you can possibly afford the time, and remember, my time is not important, you need to check everything that is done.  Medicine is complex, although we have other complex systems in society which work a lot better.  “We’re different from them,” say my colleagues.

Yes, we are different.  We don’t fix our bad systems, and we marginalize those who try.  I am proof of that.  Once I left medicine, I heard horror stories from just about everybody I spoke to.  Many of these may not be true, but tell me:  how many people each year die from medical errors?  We have estimates, but they are poor, which to me is a travesty.  With sampling or a census, ability to keep the findings from discovery, we could review each death from each hospital and sort it into:  definitely caused by medical error; significant, but not fatal, medical error; not significant medical error; no medical error.  Each chart could be reviewed, and we would have a superb estimate of the number for a calendar year by January 31 the next year.  Additionally, we would know what the errors were, and we could learn from them.  Legislation to do this was written by me, had 10 co-sponsors in the Arizona legislature, which was 8 more than the number of doctors who supported it.  The Hospital Association killed the legislation.

We physicians want malpractice reform, yet we act as if bad outcomes are just bad luck.  They are usually due to a concatenation of bad systems that can be fixed, not tolerated.  How many and what kind need only to be counted.  To people like me, who live and breathe numbers, “count” is always modified by the adverb “easily”.

Instead, I have encountered verbs: to marginalize, to ignore, to frustrate and to fail.