Archive Page 62
“Can I run a case by you”, my younger colleague asked.
“Certainly”, was my obvious answer.
She proceeded to tell me about a patient who had been to the emergency room recently with abdominal pain, jaundice, profound fatigue and itching. Her liver enzymes were elevated but her imaging did not show anything abnormal, from the appearance of her liver to her gallbladder, bile ducts, pancreas and everything else.
My colleague saw the patient in follow up and all the hepatitis and mononucleosis tests from the emergency room had come back negative.
She asked “What do you think this could be?”
“Well they checked for all the usual things“, I said and started googling on my laptop. “I have an idea.“
I soon found what I wanted, and said “I’m printing an article. This is something I learned about not all that long ago, but it made a big impression on me.“
The printer rattled behind me and my phone rang. It was a specialist at Cityside needing to talk to me. I said to my colleague “read this and see what you think”.
After I finished my call I went down to her office. Her nurse exclaimed as I walked through the door “you’re a genius”.
Sally was reading the article I had printed about G.I. manifestations of tickborne diseases. “It fits”, she said as she ticked (Sorry, but love puns…) off all her patient’s symptoms from the table in the article.
I told her about the lesson I learned from Dr. Kim about anaplasmosis and very soon afterward was able to share with a young colleague. It still isn’t that well known a disease, but its incidence in Maine is increasing dramatically.
So Sally softend her nurse’s compliment and said “experience counts“. I don’t deserve to be called a genius, but I do like being recognized as experienced. After all, it’s been 42 years since I graduated from medical school.
Travis no longer had the severe belly pain he went to the emergency room for last month. He was just in for a routine physical. He seemed healthy enough, but as we talked, I saw that the ER note in my EMR made reference to a CT scan that we never got a copy of. The ER report just said that the scan showed nothing acute.
The pain he had experienced was excruciating and lasted a few hours. It made him vomit and it was right in the epigastrium, just under his breastbone. It went away as suddenly as it had appeared.
I logged in to Maine Health InfoNet and located his CT report. It contained two abnormalities.
First, there was “streaking” around the gallbladder and sludge or small stones. I showed the report on the screen of my laptop and explained that very small gallstones can pass down the bile ducts into the small intestine. When they do, the pain is just like the one he had. If they get stuck, the pain doesn’t go away like his did, you get jaundiced and need to get an ERCP hundreds of miles away to relieve the obstruction.
“You need a gallbladder ultrasound”, I told him. “Believe it or not, ultrasound is better than CT at showing stones and sludge in the gallbladder. If you have lots of little stones there, you’d be better off having your gallbladder removed in order to prevent a disaster later on.”
The second abnormality was an unusual appearance of the bones in his pelvis, possibly a bone cancer, but statistically more likely to be completely benign. But the report recommended additional X-rays of his pelvis.
“Why didn’t they tell me all this?” He seemed incredulous.
“This happens all the time”, I explained. “They may only have a preliminary report from a teleradiologist in a different time zone, stating just ‘nothing acute’, or they may rely on making a blanket recommendation to ‘follow up with your PCP’ even if you feel well.”
“They did say that”, he admitted. “But I felt fine.”
“Their job is to decide if a patient needs emergency procedures”, I went on. “Their system would be completely bogged down if they had to arrange followups for what we jokingly call incidentalomas, things that may or may not be signs of disease. Many people think primary care doctors go through outside reports in great detail as they come in, but there is no time in our schedules to do this when we see patients all day long. Thinking we can do all that on the fly or in our spare time is a flawed business model. So the safest and most practical way to handle things is to have a followup visit after an emergency room workup has taken place.”
“Boy, I’m glad I happened to have this appointment”, he said.
“Like I said, this is so common. A couple of years ago I saw a young man like you for something routine and he had been to the ER, too, at a different hospital. When I went over his CT report, it turned out he had a small kidney cancer. He had surgery and is fine now. But I possibly saved his life. And I have many other stories like that.”
I have written about this kind of situation many times. It is an important reason to have a primary care doctor, a medical home. The bureaucrats have created many models and “workflows” for following up on emergency room visits, but as they rely on non-physicians, they risk adding fluff without medical insight.
“Follow up with your doctor” is a safer bet, because as much as I would like every doctor’s motto to be “If you find it, you own it”, that is not the way things work in healthcare these days.
Last month I saw a woman with a few weeks’ history of pain and swelling around her left ankle. She hadn’t injured it and she had no history of gout or arthritis. It was swollen and tender but not red or warm. Moving it hurt her and she walked with a limp. I ordered an X-ray, which was negative, and some bloodwork. Her inflammatory markers were high, uric acid level was normal and antinuclear antibodies and rheumatoid factor were negative. I prescribed a nonsteroidal and referred her to orthopedics.
Almost a month later I got a call. It was the orthopedist:
“Your Mrs. Patterson – she’s got lymphedema up to her thigh. There’s nothing wrong with her ankle. I’m sending her back to you for a lymphedema workup.”
I gulped.
“She only had swelling at the ankle when I saw her a month ago, so this has changed a lot”, I said as our conversation ended.
I made sure to see Mrs. Patterson the very next day.
“That orthopedic doctor didn’t think much of your diagnostic skills”, she said. “But I told him all this other swelling happened after I saw you.”
Being the first contact in a new disease process always involves the risk of missing diagnoses and looking stupid. The last person to see a patient has all the advantages: more time for the disease to evolve and more previous tests and treatment failures to take into consideration.
Emergency room doctors, hospitalists and specialist consultants need to be honest when they disagree with the primary care physician. But they have a choice whether to assume all the diagnostic clues were there when we saw the patient or not. They also have a choice whether to be graceful or degrading if we were indeed on the wrong track when we saw the patient.
We strive for perfection, but none of us are perfect. That is the scary part about being a doctor in this litigious society. But we are in fact not held to the standard of always being right. We are only required to do what a reasonable clinician would do under the same circumstances.
No insurance company would cover a lymphedema workup for modest ankle swelling. Ordering that would have been inappropriate, wasteful and excessive.
But, as I think back on this particular case, I have once again formulated a resolution. Since I am practicing in an area where it often takes a long time for patients to get an appointment with a specialist, I need to be even clearer than I have been in telling my patients:
“If things get worse before the consultation, I absolutely need to hear about it.”
A Country Doctor Writes: 
