Thursday, March 15, 2012

Offensive, Defensive Medicine

Case: 54 year old male with intermittent bulge to right inguinal area accompanied with intermittent,  sharp pain.

Class? Diagnosis? Treatment?

Class, how should this be diagnosed?

Reality. Internist has an idea... does KUB.... it may show a nephrolith. Internist prescribes antibiotics and steroids. Refers Urology.

Urology is not sure.... orders CT scan. CT does not show stone.

Patient sent home. Still in pain. A week later goes back to internist with picture of said 'bulge'. Internist has more clear idea. Refers to General Surgeon #1. General surgeon #1 thinks he knows. Refers to General surgeon #2 who disagrees with General surgeon #1 but agrees to operate anyway. Is surprised there is a CT Scan that has been done. Inquires as to results of scan. They are negative. He operates anyway and discovers, three weeks into course of illnesss...


And what did we learn?


  1. Discovers that he had an inguinal hernia all along and that all of those tests andconsults were unnecessary.

  2. Discovers that he had an inguinal hernia all along and that all of those tests andconsults were unnecessary.

  3. Christine,
    so right you deserved to say it twice. But I have a larger story to weave here, because forty years ago this would have been close to malpractice. So how did we get here?

  4. The presenting Hx sounds so much like an inguinal hernia. Why wasn't he referred to surgery immediately rather than having the internist get stuck with him? Either way it would have been a surgical issue, whether hernia or ureter stone...

  5. Turn your head and cough...

  6. It's easier in court to validate an operation based on symptoms than it is to validate not operating when the thing you weren't sure about is now a strangulated hernia and the patient is septic and dying. When in doubt, CYA. Just like the chronic migraine patient who comes in every 1st of the month with a headache that is 15/10. Get that CT because the one time you don't is the one time she will have the brain bleed.

    And on that note, always look at the scans yourself. Things are missed either by the radiologist or CT scanner. And when a radiologist is looking for a stone, he may not be looking for a hernia. Nothing like reading the radiologist's report and seeing, "clinical correlation necessary." The only job in medicine where you don't have to be right and you never have to commit.

    One can easily learn that 3 hours into any ER rotation. Every tax payer should spend a little time in the ER as an observer...

    1. Isn't that why the radiologists favorite flora is the Hedge?

  7. Intermittent Bulges?
    I get Intermittent Bulges all the time, then I (redacted) and they go away.
    Don't need no CT or light-in-the-crocs-Internist messin' round with my stimulus package.

    So what Army Hospital was this?...
    and whenever you hear some Hospital Suit bragging about their perfect J-Ko Score, just remember.
    Walter Reed passed J-Ko.
    That hospital in "One flew over the CooKoos Nest" passed J-Ko
    And if Hitler allowed J-Ko in, Treblinka's Hospital would have passed J-Ko(very clean showers).
    You know what hospital DOESN'T pass J-Ko?
    NONE!! its like tryin to find a "Non-Gifted" class in our "World-Class" Pubic School System.
    A White NFL Defensive Back...
    An SEC Football School in this Bad Joke they call "March Madness"
    I don't know about you, but in MY family we don't joke about Mental Illness.
    Seriously, what Real Sport broadcasts on TRU-TV???
    There I was, Bowl of Popcorn, Icee Cold Bottled Coca-Cola(the REAL Kind, from Mexico)ready to watch some Nancy Grace, and get West-Arkansas(Hot Springs)Normal-College vs the 14th place team from the Big (L)east...


  8. Dear Ravi,

    My question exactly. My thought is that in our current legal climate and after years of being told to "CYA" that without a confirmatory study neither the internist nor the surgeon wanted to trust the history and physical exam. Terrible.

    the week,
    sound points all. but why not trust the physical exam and history? I mean at some point what happends to history and physical?

    *golf clap*.... not even sure what the point was, but wow. you continue to amaze. never stop doing that voodoo that you do, SO well.

  9. H&P's are all just re-runs from the IM and or ER docs anyways. Nothing like watching the specialists read from the IM's H&P while dictating. That's why I chose ortho. Well that and I got tired of carrying around a stethoscope.

    So the IM doc types the note on the VA EMR. Urologist sees note and KUB results and assumes that the IM doc did a thorough H&P to rule out other causes of the symptoms and since the KUB showed a possible stone that needed to be "correlated clinically", he does a "urologist physical" and orders a CT. So CT is negative for uro trouble so he sends him home. Patient does some heavy lifting and is able to take a pic of the hernia before reducing it. IM doc sees pic and sends to GS#1. GS#1 reads notes from IM doc who thinks stone and uro who says no stone and IM note #2 that thinks it's a hernia. He does an exam and finds said hernia and refers to GS#2 who is the hernia guru. GS#2 reads previous notes, but had trouble finding bulge as perhaps it is reduced again. He sees a CT was done and reads note from uro who says "CT was negative". But because 2 out of 4 docs say hernia, he has to operate because any lawyer can find an "expert witness" to testify that there was a high level of suspicion for a hernia.

  10. the week....

    yes. that about explains it. forty years ago there was an internist who felt the hernia, a surgeon he called, and a fix. the end. total bill, a few thousand dollars.... tops.... minimal liability, and if the patient didn't have insurnance they paid. guess I'm a freaking dinosaur. but ortho huh? yeah, shoulda done it myself. man the barricades doc, they are coming for you next.

  11. Vandals at the gates...

    The Amish still pay cash, don't they?

  12. yes they do,
    because they know it's the most inexpensive way to get quality care. they are tricky.

  13. "IM doc types the note on the VA EMR. Urologist sees note and KUB results and assumes that the IM doc did a thorough H&P"

    Bwahaha. I've worked at a couple VAs, haven't seen too many IM docs there who can get a decent hx much less do both a hx AND a good physical exam.

  14. OK, I like to bust on those Homo-Internists as much as any red-blooded (Real)American but...
    (With Apologies to Quinton Tarantino)
    Ringo:"Bustin Internists Balls ain't the giggle it used to be, 1/2 of em dont even speak English, you say "How's it hangin Flea?" they don't even know what the F*** your sayin..."
    and I remember the time I snatched this Fleas Turban off.
    THATS RIGHT HE WAS WEARIN A FRIGGIN TURBAN, right there in the Washington Hospital Center ICU.
    and had one of those long ZZ-top beards, which didn't come off, cause it was real...
    And in the 90's the idea of someone wearing a Turban and long beard in the ICU was so farout I just assumed it was one of my resident buddies playin a goof...
    Too bad he was head of Interventional Cardiology :(
    Oh yeah, my point.
    How come nobody busts on Urologists?
    Good Grades, Normal Personalities, Can trace there lineage back to the Mayflower, could pick any specialty,
    and they pick the one where you handle Doogans 24-7.
    OK, even if its only 9-5, thats about 9 more hours of Coc* than I wanta deal with...


  15. 911Doc:

    Great blog...ambled over from Maha's blog. Love this one. BTW I work with a great internist and she gives those specialists duh moments all the time. And I know VA really well (so does she)!

    This is probably why radiology and surgery don't want to take her calls. She's crafty, though. She gets someone else to call.

    And she's also an American.

  16. Rehab RN,
    Certainly this would be a typical VA encounter. The "Holy cow!" part of this is that the patient was well insured and in with a major university group. Medicine is sick.

  17. Where have all the Cowboys/girs gone? Answer: Plastics, and vein clinics.


  18. @9-11
    Well I've never been one to let a Dead Horse go unbeaten, but,
    "Holy Cow!"! an underutilzed Expletive if there ever was one...
    I tried bringing back "Gee Whillickers!" a few years ago, went over about as well as Khallid Shiek Mohammed at a Knesset Meeting...
    Of course now-a-days you'll have PETA, Al Sharpton, and that Vietnamese Monk who set himself on fire picketing your blatently anti-Hindu Slur.
    Indians really do believe Cows are holy, thats why they don't eat em.
    Don't ask me about the whole dot on the forehead thang.
    And we don't eat Cats/Dogs(knowingly)in this country, doesn't mean we have to worship them.
    And howcome protesters never set themselves on fire anymore?
    I'd sort of LIKE to see Al Sharpton in flames.
    His hair anyways,


  19. So Frank... I see you've opened the summer house. Are you going to spend any time there?


  20. SCRN,
    way inside baseball there...

    Hot-diggity dog

  21. "Inside Baseball"?
    More like a Moe Drabowsky Fastball over the Backstop...
    Summer House Summer House Summer House....
    Closest Ive got is the tool shed where I smoke the cigarettes I dont smoke anymore...


  22. OK then, the tool shed where you used to smoke (your blog).


  23. Nah, "Frankie's Hideout"'s been swept into the Dustbin of History, along with other out-of-date concepts like playing fair and a Homo-Free Military...
    but stop the presses, looks like Tim Tebow's goin Kosher...


  24. That's a shame.



    My homegirl. Her album drops May 22. The video here is bootleg. It will be available soon as well. Somehow I just know you "guys" will enjoy and even maybe buy her video... OK, you are a homo if you say you don't like her!


  26. Someone somewhere must've been mentally shouting "HERNIA" on seeing this patient. Surprising that everyone was more preoccupied with covering their own backs.

    A gem from an Ortho I know, "You order investigations to confirm a diagnosis you have in mind, not to cook up a differential"