watchful waiting

Tuesday, February 15, 2011

It has been a difficult week for many athletes. Continued concussion symptoms caused Lindsey Vonn to withdraw at the world skiing championships even though she passed the US Ski Team testing protocols. Paul Pierce of the Boston Celtics is waiting for MRI results trying to find out why his foot hurts and golf’s Ernie Els has decided that his sore neck will keep him off the course this week. Three unrelated injuries in three unrelated sports all linked because not everything in medicine can be diagnosed with a blood test or X-ray.

Medicine has an image problem. Television shows like House and CSI use technology to move the plot along, getting answers based on scientific tests available and completed within the show’s hour format, give or take 15 minutes of commercials. Real life could only hope to be so efficient but the timeline for many injuries and illnesses may take hours and days because observation is sometimes a key element in the evaluation of a patient. Unfortunately, watching patiently does not make riveting television.

Lindsey Vonn’s concussion saga is pretty routine. After a minor head injury sustained in training, she was repeatedly evaluated by the ski team physician and after being cleared, tried to race. She felt sluggish and that it was difficult for her to concentrate and react causing her performance to suffer. More importantly at high speeds, she was putting herself at risk for another fall and injury. CT scans of her head had been normal and her neurologic examinations had been repeatedly normal but Vonn failed during real life. The lesson to be learned about concussion is that technology does not answer all when it comes to the brain. If an elite athlete cannot react while skiing at 60mph, what hope is there for a patient with a similar minor head injury driving a car on the freeway.

Not too long ago, time was an ally in sorting out orthopedic injuries. Certain broken bones would hide on plain x-rays and care temporized until the body would let us know what was wrong with it. A scaphoid bone fracture in the wrist was a prime example. The diagnosis was often made clinically because of swelling and pain over the snuffbox, an indentation at the base of the thumb. The x-ray was notoriously unreliable and sometimes took a couple of weeks to turn positive and reveal the break. Treatment was conservative. Cast the wrist presuming that a fracture was present and bring the patient back for a recheck and repeat x-rays in about 10 days. Broken bones take a lot longer than that to heal and if the pain was gone, the bone likely wasn’t broken. All that was lost was the inconvenience of the cast. If the pain persisted, then more testing might follow.

Technology also depends upon timing. A test needs to be ordered at the appropriate time, otherwise, the results might be called into question. It can take up to 12 hours for a CT scan to show the inflammation of appendicitis. The blood tests that help diagnose infectious mononucleosis or Lyme disease can take a few days to turn positive. Sometimes the answer to a patient’s illness is based on the time it takes for the care provider to take a history and examine the patient.

The art of medicine lies in the skill of talking to patients, understanding their complaints and touching the patient to allow the appropriate use of technology. Perhaps the more important skill to be learned by both doctor and patient is patience. It’s unfortunate that television can’t sell the Observation Channel to audiences and sponsors. Then, perhaps, the skill of watchful waiting might win an Emmy.

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