Monday, March 23, 2015

One of the joys of the college basketball post season is the potential for the unexpected. The small school underdog can celebrate a Cinderella win against a larger and stronger opponent, at least for one round. Upsets occur and those filling out their bracket bemoan the fact that what was expected did not occur. They play the games because nothing is guaranteed. Welcome to March Madness. That same lack of a guaranteed win also exists in the medical world, where things don’t always go according to plan, but it’s call a complication, not an upset.

Some complications are inconveniences. After surgery, there may be a little bleeding from a wound and nothing more than an extra bandage is needed. There may be an extra day of discomfort. Nausea can occur after taking a pain pill. Other complications, however,  can be devastating. Death comes to mind as one particular example. The goal of modern medicine is to minimize complication rates by improving techniques and care, yet for the individual patient who experiences a complication, theirs happens 100 per cent of the time. For that reason, the patient and family need to pay special attention to the informed consent discussion that happens with every medical encounter.

Not so long ago, the relationship between doctor and patient was one sided and paternalistic. The science of medicine was progressing nicely by improving diagnostic skill, but there were few treatment options available to offer to a patient. It was easy for the doctor to dictate the terms of treatment. There was but one way to treat a specific problem. Over time, the medical world has evolved and alternative treatment approaches exist for many illnesses and injuries. Ear infections can be observed for a few days before jumping to write an antibiotic prescription. Some fractures do not need emergent surgery. Cancer therapy can offer a myriad of experimental options. But each option carries its own risks and rewards.

Not so long ago, a knee injury ended an athlete’s career, but with technical advances like arthroscopic surgery, it is almost routine to “fix” knees. The goal is to return elite athletes and weekend warriors alike to their previous level of activity. However, that routine surgery is anything but. Some type of complication may occur in almost 5% of arthroscopic knee surgeries, and the more complicated the knee repair, the higher the potential risk. Infections may affect 1% of patients, anesthetic problems occur in 1 out of 250 operations and a pulmonary embolus, or blood clot to the lung, occurs in 1 out of 1000. This last number is very tiny, but pulmonary embolus is one of the most common causes of sudden death.

The discovery of antibiotics changed the world for medicine and allowed infections, like pneumonia, that were once a death sentences to be treated and cured. Doctors liked antibiotics so much that their indiscriminate prescribing increased resistance rates, making some bacteria relatively immune to common drugs. Plus, docs felt that patients would be less than satisfied if they did not leave their appointment with a prescription in hand. Some complications were irritating. Patients who were prescribed amoxicillin for a presumptive sore throat and strep infection, would develop a whole body rash if their real diagnosis was infectious mononucleosis…but who wanted to bother with the time and expense of a doctor’s visit if a prescription could be called in over the phone instead. But even with the proper use of antibiotics, unintended consequences could occur. Clostridium difficile, C Diff, can cause significant diarrhea due to colitis, or inflammation of the colon, in some patients who have been treated with antibiotics. The drug wipes out the normally present colon bacteria and lets the C Diff run wild. This infection can be devastating and may take weeks to cure. Once thought only to be a hospital acquired infection, C Diff, now rears its ugly head, even in the outpatient world.

Every doctor patient interaction has the ability to have an unintended consequence or complication. Care and treatment plans have become a collaborative decision making process. Deciding to watch and wait may cause an illness or injury to worsen instead of improve. Being aggressive with a medication can lead to cure or complication. The same holds true for the timing and type of surgery that might be recommended. The doctor has the responsibility to explain the ups and downs of alternative treatments. The patient has the responsibility to listen and ask question so that an informed decision can be made.

And there is one certainty that holds true. There is never a sure thing in medicine or March Madness.

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decision making

Monday, February 9, 2015

The press release was very black and white. Blake Griffin, star of the LA Clippers, requires surgery for an infected elbow. If only medicine was so cut and dry and just one option was proven to be effective. But in the real world of caring for patients, this short story does not do justice to the sometimes complex treatment alternatives that might be appropriate when caring for an injury or illness. Alternative treatment approaches mean that the physician and patient may have to come to a consensus about care, even when the medical literature and research cannot give much guidance. This may be the lesson to be learned from Griffin’s elbow short story.


The olecranon is the point of the elbow and there is a small bursa or sac that protects the skin from rubbing across that pointy bone edge with every bend of the elbow. On occasion, the bursa can become inflamed, either because of one acute blow or because repeated falls, resulting in bursitis (itis=inflammation). There is pain and swelling and the diagnosis is pretty easy because the swollen sac appears as a small knob overlying the elbow. Usually, it resolves with PRICE (protection, rest, ice, compression and elevation). Competitive athletes may not be allowed the time to rest and injecting the bursa with steroid may help with healing.

Sometimes the bursa becomes infected. Most commonly, the skin overlying the injury is damaged due to a laceration or abrasion, but the infection may arrive in the elbow after traveling through the blood stream from another site. The infection may also be a complication of aspiration, when a needle is used to inject steroid. And this is where the Blake Griffin treatment discussion begins.

The research is confusing and does not come to a consensus. Some studies suggest that the best outcome for infected olecranon bursitis occurs with a prolonged course of antibiotics. Other studies suggest that immediate surgery is appropriate. Yet others recommend surgery only after antibiotics have been started or have failed to produce a cure. depending upon the researcher, those antibiotics might be recommended to be administered intravenously or by mouth, depending upon the severity of the infection.

The treatment successes are confusing. In mild infection, antibiotic therapy can fail from 10-30% of the time while sever bursitis has a failure rate up to 50%. When it comes to the research though, the definition of mild versus severe is not set in stone. The severity of an infected olecranon bursa is in the eye of the beholder; mild to moderate infection is described as having local, significant inflammation while severe infection will show intense bursitis. There are other associated symptoms to look for, but it’s tough to know how significant “significant” is and how intense “intense” might be.

Those who advocate surgery as the first treatment option point to the statistics that show recurrent infection that happens “only” 15% of the time when the infected bursa is removed. If surgery is considered, the use antibiotics don’t decrease the re-infection rate. The type of surgery is also open to debate, including whether to leave the skin open and allow healing to occur over time, or whether the skin should be closed immediately. There are some surgeons who advocate operating with an arthroscope to make the smallest cuts possible, while others suggest a wide incision as better choice.There are a variety of other combination treatment approaches using antibiotics by mouth or intravenously, in association with surgery that are touted, depending upon the individual situation and that is the crux of the matter.

Once upon a time, the practice of medicine was all about diagnosis and there were few options available when it came to treatment. Modern medicine now has many more tools to help establish a diagnosis and offer different ways to approach treatment. It is the physician’s responsibility to teach the patient and family about different options, their benefits and risk, and to come to consensus about which plan best fiuts a particular patient’s situation. That does not mean that the physician needs to take a back seat in the decision making and agree to do something that is harmful, but it does mean that the patient has some responsibility in what happens to their body.

Much goes into the decision that cannot be summarized by a story that proclaims that Blake Griffin needs surgery. The decision may rest on the facts of the case: there is the history of repeated needle aspirations of chronic bursitis, there is an infection that occurred after the most recent injection and there is the importance that he and his team are in the midst of a playoff race with his return to play vital for his team’s success.

Those same considerations exist for those who are not famous and don’t live their lives in the public eye.  The same discussion issues exist in treating a kid’s ear infection with or without antibiotics, choosing a cast or operation for a fracture or deciding to admit or send a chest pain patient home. Decisions happen every day in medicine and it’s up to the doctor to remember to educate and up to the patient to ask to be taught.

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