Too many tests

Monday, August 25, 2014

In our mind’s eye, we could all throw it like Peyton, hit like big Papi and be like Mike. But while we aspire to their greatness, we should not ask to have their medical testing inflicted upon us. Today’s elite athletes can no longer be content with medical opinion, rather they or their team management expect that the latest technology be used to help make the diagnosis.

The latest victim of this syndrome is Carolina Panther quarterback, Cam Newton, whose rib injury during a preseason game might have been diagnosed with a brief history and physical examination. Mere mortals might have needed a plain chest x-ray but Mr. Newton also got a CT and MRI of his chest. The verdict? He had a nondisplaced rib fracture. And how did those extra tests affect his care and treatment? They didn’t.

Medicine has gone high tech with imaging tests that can peer inside every nook and cranny of the body to find things that may or may not matter. Chest wall injuries area prime example of what if gone wild. The ribs and muscles that make up the chest wall serve a couple of purposes. Most importantly, they act as a bellows, swinging up and out to suck air into our lungs to help us breathe and then again squeezing back in to make us exhale. It doesn’t matter if a rib is bruised or broken, the pain of either injury makes it difficult to take a deep breath and that interrupts the mechanism of breathing. When the lung does not adequately expand with inspiration, the patient runs the risk of getting pneumonia, an infection of the lung, and that is the great complication of a rib injury. The ribs also protect those organs that are located beneath. The lungs are obvious but the lower ribs also protect the spleen and liver in the abdomen and lower chest trauma can cause damage to the upper abdomen.

This is where the art of medicine comes in. Taking a history allows the doctor or other care provider to understand how much force was inflicted upon the patient and understanding the patient appreciates how much force they can withstand. A frail elderly patient who falls against a countertop and injures ribs is perhaps more likely to have underlying damage than a padded quarterback being hit by a linebacker. The physical examination can help decide whether a small area of the rib cage is damaged or whether numerous ribs are injured. The larger the injured area, the more likely that the breathing mechanism is compromised and the potential for complication increases. For most patients, a plain chest x-ray is adequate to look not for rib fractures but for a pneumothorax (collapsed lung) or pulmonary contusion (a bruised lung). Ordering rib x-rays to look for a fracture is a waste of time, money and radiation. Physical exam will also tell you whether there is enough abdominal tenderness to us CT to look for internal bleeding.

But the art of medicine is not infallible and perhaps that is feeds the fear of missing an injury. Green Bay Packer center TJ Tretter hurt his knee early in the game against Oakland but played on after doctors evaluated him on the sideline and cleared him. Unfortunately, he had a fracture that will sideline him for the next many weeks. The same fear also feeds the use of CT to routinely evaluate concussions when there are clinical guidelines that can help decide who needs a scan and who doesn’t.

One can appreciate the high medical tech approach to those athletes whose salaries run into the tens millions of dollars and those teams who market the player to their maximum advantage, yet the general population takes their cue from what they see on the field, on the sideline and in the training room. Ideally, regular folk should ask the doctor why a test is being ordered and what benefit it will bring. Sometimes, tests are ordered just because with little thought. Other times, the decision as to what test to perform takes great thought. Sometimes, there is risk management involved. The doctor doesn’t want to miss a diagnosis, not only for the patient’s sake but also for fear of being sued. In many situations, if the patient were asked, they might agree the risk of missing the diagnosis was not enough to perform an expensive or painful test.

This shared risk happens routinely when a diagnosis has been made and treatment options are being contemplated. The patient often helps decide if they want aggressive or more conservative treatment options or perhaps an operation now or later. There is no reason that the process of involving the patient cannot happen earlier in the diagnosis phase as well. The key is communication is to allow the patient to become a partner in the all decision making process and not the object of it.

For Mr. Newton, his ribs are going to hurt for the next few weeks, regardless of whether they are broken or bruised. It will hurt to take a deep breath or to twist to throw or hand off the ball. It won’t matter that it took a CT scan or MRI to make the diagnosis of the broken rib. A good physical exam might have been enough, but it wouldn’t have been perfect…but even the best rarely are.

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blood clots

Monday, August 11, 2014

In August, a Philadelphia sports fan should be thinking about the Eagles and the Phillies but not necessarily the Flyers…okay, perhaps not the Phillies either, so it would have been easy to miss the news in the City of Brotherly Love, that Flyer defenseman, Kimmo Timonen, was hospitalized in Finland for blood clots in his leg and lung. The 39 year old was supposed to play an important role for the Flyers in the coming season, but team General Manager Ron Hextall was uncertain whether he could play: “This could be a long term thing…Could he play next season? I don’t have an answer to that.”

The answer begins with the treatment for DVT, deep venous thrombosis or blood clot in a vein, and PE, pulmonary embolism or blood clot in the lung. Anti-coagulation or blood thinning is the treatment of choice for both DVT and PE and while on that treatment, Mr. Timonen will not be playing hockey. By interfering with the body’s ability to clot blood, minor injuries can become major disasters, especially in hockey where falls and body contact are routine parts of the game. A minor bump to the head can cause lethal bleeding in the brain. A blow to the chest or abdomen can cause uncontrolled bleeding and shock if the body cannot mend itself. The big question to be asked is how long does he have to be on blood thinners? And that is where the science of medicine is not quite as precise as we have come to expect.

There are a few reasons why a blood clot or thrombus might form. The big three categories are vein injury from trauma, blood stasis and problems with the blood clotting mechanism. If the body is immobile, there is less muscle activity to squeeze blood back to the heart and stagnant blood tends to clot. Patients who are bedridden due to stroke or surgery (especially after pelvis, hip or leg operations) and those that have casts in place are at risk, as are people who sit in an airplane or car for hours. Decreased blood flow from the legs may also occur in obese people and can also be seen in pregnancy where the enlarged uterus compresses veins in the pelvis. Underlying medical problems can increase the risk of blood clot formation and range from genetic predisposition, to cancer, to smoking and the use of birth control pills.

DVTs are common but the big complication occurs when the thrombus breaks off and embolizes or travels through the heart and gets lodged in the lung arteries. More than 600,000 people are diagnosed with a PE every year in the US and the death rate is about 25%, but those numbers may significantly underestimate the problem. Based on death studies, there may be more than double that number and the diagnosis of pulmonary embolus often occurs autopsy. When a PE occurs, it affects the ability of the lung tissue to transfer oxygen from the air in to the blood stream and depending upon the amount of clot, the symptoms may be mild (sharp chest pain and mild shortness of breath) to collapse and sudden death.

The diagnosis is always in the back of the doctor’s mind to at least be considered when caring for people with shortness of breath. The diagnosis is entertained based upon history, physical examination, clinical suspicion and risk factors. It is confirmed in a variety of ways depending upon the clinical situation and the patient’s stability. Often, it may include, EKGs, blood tests, ultrasounds and CT scans.

For most people the treatment is anticoagulation, the use of medications to thin the blood. There are a variety of choices, depending upon the patient’s situation but most involve a combination of heparin injections to immediately thin the blood while also taking Coumadin by mouth. It takes a few days for Coumadin to reach effective blood levels, so dual therapy often occurs. Newer anti-coagulation drugs have been developed and in the past few months, Xarelto (rivaroxaban) has been approved as a single step oral treatment for PE. But in critical situations, emergency surgery may be required to remove or dissolve blood clots in the lung.

With that background, the question remains. How long should treatment last? For the first DVT or PE, anticoagulation is recommended for 3 months, as long as there is no underlying reason to consider longer therapy. Imagine a cancer patient or one who has an abnormal blood clotting disorder. For recurrent clot, the recommendations are less clear and consideration may be given to life-long treatment. The duration of therapy recommendations are more than a little vague for those patients.

This is the second time around for Mr. Timonen with clots. In 2008, he developed a DVT after being hit by a puck in the foot. Now the questions that face him and his doctors include whether that first DVT was due to trauma and does not count in deciding how long the anticoagulation should last. And they need to decide what caused this episode of DVT and PE and whether there should be a search for any underlying risk factor. And that leads to the question posed by the Philadelphia general manager as to whether Mr. Timonen will play in the coming NHL season that begins in about a month. And the answer is…not anytime soon.

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