when tests don’t matter

Wednesday, August 25, 2010

As the great egg recall rolls out across the country, the salmonella scare continues to spread. Finding and destroying a half billion eggs sounds like it might wipe out the country’s egg supply but it is only a tiny fraction of the 80 billion eggs that are produced by US chickens. Few people will become infected, but that will not stop growing numbers to seek medical care to make certain that they are alright. The challenge for the care provider will be to meet the wants of the patient with the reality of what can be provided.

As with every doctor’s visit, the patient has certain expectations. Sometimes they are voiced but many times, they are unasked. A patient who comes in with a headache wants to be reassured that there isn’t a brain tumor present. The parent who has a child with abdominal pain wants to hear the words that appendicitis is not the cause. When people come to their doctor this week with vomiting and diarrhea, they want to be reassured that they are not potential victims of their morning breakfast of eggs over easy and salmonella infection.
Normally when we eat, the stomach acts like a mixing bowl, taking the food and turning it into a slurry. The watery mix passes through the small intestine where nutrients are absorbed into the body and is then delivered to the colon or large intestine. The colon acts like a sausage maker squeezing the stool along, allowing water to be absorbed back into the body and producing a solid bowel movement. When the stomach becomes irritated, it empties itself quickly by vomiting. Irritation of the colon causes it to squeeze down is a single spasm causing pain, and when it relaxes, the liquid stool rushes through the whole length of the colon with no time to allow water to leave. Out comes a liquid, diarrhea bowel movement.

The difficulty with the latest egg scare, is that symptoms of salmonella infection are exactly the same as any other cause of gastroenteritis (gastro=stomach + enter=intestine =itis=inflammation) or “stomach flu. And the symptoms of vomiting, diarrhea and crampy abdominal pain are usually caused by a virus.

The vast majority of people who have these complaints will not have salmonella. Sometimes it’s hard for patients to accept that the treatment is the same. Antibiotics are not used for salmonella, except in patients who have a compromised immune system, and the illness is allowed to run its course and usually resolves in a few days. If the symptoms are the same and the treatment is the same, there is little need to do any testing. Salmonella can be confirmed by cultures a stool sample, but for what purpose? The results will come back (positive or negative) just as the illness is resolving itself. How frustrating for the patient to be told that there is little to do except for supportive care and prevent dehydration.

When a test doesn’t matter, should it be done? Aside for the cost and messiness, there is little reason not to do stool cultures, except that if every patient demanded the testing labs across the country would be overwhelmed and other tests would be delayed. For other illnesses, there are consequences and potential side effects for unnecessary testing. A ”routine” CT scan of the head increases the radiation risk of cancer. Even the lowly blood test can cause bleeding or skin infection because of the needle stick.

As with most illnesses, prevention is the best treatment for salmonella. While the government and the food industry work on their recall, consumers can minimize their risk by cooking their eggs well. Thorough cooking kills the salmonella bacteria which means that over easy is out and the morning protein shake of raw eggs made famous by Rocky and Sylvester Stallone is definitely out.

And as for the next doctor’s visit, try to puts words to the purpose of the visit and ask the questions you want answered. While they can anticipate, sometimes they get it wrong and that can lead to an unhappy patient and unsatisfied care provider. Players on the same team need to communicate to get to where they want to go.

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