Monday, April 13, 2015
After the first week of the season, the rules to speed up the game of baseball may be having some effect. Games are taking a little less than 3 hours to play, about 6 minutes shorter than last year’s average. It seems that what was once America’s past time, is suffering because the combination of a shortened attention span and the inability to be patient has caused its popularity to wane. People don’t tolerate waiting very well, even if the reason for that wait is compelling. And that brings us to why people wait in the ER.
If one were to watch Grey’s Anatomy ER or Nurse Jackie, it would be quite reasonable to assume that all medical problems could be solved in 44 minutes; the rest of the hour is filled with commercials and next week’s preview. But technology has yet to catch up to what is portrayed on television and movies. The idea that technology cannot be rushed is anathema, not only for the patient and family who are actively being cared for, but also those who are waiting fro the next ER bed to be open or nurse who can provide can provide care.
Patient flow in the ER is at the whim of available technology and even though the calendar says it’s the 21st century, high tech does not necessarily equal high speed. Consider the child with abdominal pain. Parents often are concerned about appendicitis, an inflammation that if unrecognized, can lead to bowel perforation, significant infection and major complications. Patients often don’t read the textbook and forget to present with the classic symptoms of umbilical pain moving to the right lower quadrant, accompanied by loss of appetite and vomiting. Physical examination can be compelling and an elevated white blood cell count, that often accompanies inflammation, seals the diagnosis and the patient is taken to the OR for an appendectomy. That was the standard of care forever, or until the availability CT scans became the norm, and that standard had surgeons removing normal appendixes 15-25% of the time. It was a reminder that other things could cause right lower quadrant abdominal pain.
The good news about using technology to look into the body is that it can help make the diagnosis. The bad news is that it takes time and radiation. And here is where technology can’t be rushed. In many hospitals, if appendicitis is a consideration, blood tests might be ordered to help give direction. Depending upon the tests ordered, it might take 30-60 minutes having the blood drawn, delivering the tubes to the lab and getting back the results. Instead of rushing to CT, an ultrasound might help make the diagnosis, but that is labor intensive and is helpful only if the appendix can be identified. If not, a CT scan might be required. Often the images can be taken with just intravenous contrast injected through a vein, but some radiologists prefer having the patient drink oral contrast to help outline the intestine. If that’s the case, the drinking time takes an hour, the scan itself 10-15 minutes and then another 30 minutes or more for the images to be reconstructed and interpreted by the radiologist. Even new math can’t make the answer add up to 44 minutes.
In chest pain patients, blood tests can help decide whether a heart attack has occurred. Troponin, a chemical contained within heart muscle cells, can leak out and be measured by a blood test. An elevated blood test equals a heart attack, but it may take 6-8 hours for the test to turn positive. That means a patient who presents within a few minutes after experiencing chest pain and has a normal EKG (electrocardiogram) might have to wait many hours to find out if his heart was damaged.
The worry for women who have vaginal bleeding in very early pregnancy is not only that they may be miscarrying, but instead might be experiencing a tubal or ectopic pregnancy. One test that might help guide diagnosis would be a quantitative beta HCG, a chemical that is produced by the placenta. Its value should double every couple of days in early pregnancy and in stable patients, they may need to return in two days to help sort out the diagnosis. Meanwhile, the evaluation and care of the patient involves significant amount counseling and that take time.
Medicine and baseball share the concept that the game is not a prisoner of the clock. It’s done when it’s done, when the final out is made and when the diagnosis and treatment are complete. It is fair to try to make efficient use of time but not at the expense of the integrity of the game or the care provided. While the late Ernie Banks was quoted as saying “it’s a beautiful day fro a ballgame…let’s play two”, most people would rather get the diagnosis right the first time, no matter how long it takes, and avoid a second trip to the ER.This entry was tagged appendicitis, baseball, CT, ectopic, ER, heart attack, miscarriage, ultrasound, waiting
Sunday, March 29, 2015
Athletes like to compete. Surgeons like to operate. When injury happens, their worlds collide. Ideally, the goals of the athlete and the surgeon align; return to full time playing status at the same level of function and expertise as before the injury. Athletes tend to be more blunt, wanting to get back into the game as soon as possible and sometimes have to be protected from themselves in doing more harm. Often, decisions have to do with timing.
A pro athlete’s career is relatively short and missing even one season may be professionally and emotionally devastating. Rushing to surgery to repair an injury may be preferable than committing to physical therapy for a few weeks in hopes of avoiding an operation and then still needing to be repaired. Yet surgery is not a sure thing. Kevin Durant of the Oklahoma City Thunder broke the 5th metatarsal bone in his foot, (a Jones fracture). Surgery is usually the first option and it should have taken 6-8 weeks to completely heal, but in pro athletes, there can be a significant non-union and refracture rate. Mr. Durant developed that complication and now need further surgery and a lost year of competition.
But just because surgeons like to operate, does not mean that they always advocate for that as the first option. The success of New Orleans Pelican’s Eric Gordon using conservative therapy (non-surgical)in treating his torn shoulder labrum, is testament that the opportunity to avoid an operation should be given to everybody if possible.
The shoulder is the most mobile and least stable joint in the body. A ball and socket arrangement allows for a wide variety of movements, but its design makes it prone to become damaged and unstable. The glenoid fossa of the scapula (shoulder blade) forms a very shallow socket where the humeral head fits. The bony socket is extended by the labrum, a sleeve of cartilage that helps stabilize the joint and keep it from dislocating. The muscles that surround the shoulder are also key in that stabilization. However, in overhead athletes, (for example basketball and volleyball players, swimmers, tennis players and baseball players, the shoulder can be subject to violent forces and the structures in and around it can fray and tear.
When a shoulder labrum tears, the inflammation causes swelling and pain and this can shut down the surrounding muscles, weakening them and decreasing range of motion. Surgery can repair the damage and physical therapy can help return those functions, but the recuperation and recovery time may be as long as a year. Physical therapy alone may be successful in returning the athlete to normal function and it is a big decision for an elite athlete to forgo first line surgery in hopes that rehab alone might work. Mr. Gordon elected that second option and has continued to play throughout the season.
Mr. Gordon also used clothing made by AlignMed, also being worn by his teammate Anthony Davis and Dwight Howard of the Houston Rockets, to help with his shoulder that was recommended as part of the healing process. The shirts with built in bands that help with posture and muscle alignment have the ability, according to research from the Kerlin Jobe Orthopedic Foundation, to stabilize and increase rotator cuff function (one of the muscle groups that helps stabilize the shoulder). In another study from that group, the clothing helped increase stability of the scapula and increased muscle strength. The Stedman Research Institute found that the shirt might help decrease the risk of impingement and pain.
Most sport clothing companies, from Under Armour to Nike, make compression clothing that uniformly squeezes parts of the body. Perhaps the next step has been taken with the AlignMed concept to make functional clothing to apply pressure and help muscles, tendons, bones and joints, align more physiologically. This might allow mere mortals the opportunity to catch up to their pro athlete counterparts. Most people cannot spend hours a day in the gym or physical therapist’s office rehabilitating an injury. Work and family time get in the way. Pro athletes, on the other hand, can devote an 8 or 10 hour work day to their therapy regimens. And wearing the shirt all day long at work, whether it is on the playing field or in the office may help prevent injuries caused by poor posture and muscle fatigue.
Every patient is different and the treatment options presented and chosen will depend upon their injury, their underlying medical status and how active they were and will want to be after recovery. That said, it will be interesting to watch what happens with the Pelican’s Mr. Davis and Mr. Gordon and how they recover from their injuries. And as the baseball season begins, will players who strain or damage their shoulders look to physical therapy and clothing as an alternative to surgery. Because as Kevin Durant can attest, surgery is not a sure thing.This entry was tagged AlignMed, Anthony Davis, conservative therapy, Dwight Howard, Eric Gordon, physical therapy, shoulder labrum, surgery
Dr. Wedro weighs in
“The difference between doctors who look after mere mortals and those who look after elite athletes may have to do with how many tests they can order, regardless of the cost.”