taking time to care

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.

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spleen, kidneys and abdominal injuries

Monday, December 1, 2014

On any given Sunday, there will be a host of slow motion replays, many from multiple angles, which show in graphic detail a knee or ankle buckling. Orthopedics are the rock stars of NFL injuries, as bones, joints, ligaments and tendons are stretched, torn and broken. Head injuries and concussions are rising in awareness. Forgotten are injuries to the internal organs of abdominal cavity that are diagnosed after the game and away from the glare of the television lights. It can take time for symptoms to develop.

Sometimes you know when you’re hurt and sometimes you don’t. Cleveland wide receiver, Miles Austin, was taken to the hospital after the Browns’ game was over and was found to have an injured kidney. He, the trainers and coaches weren’t certain which play or collision caused the damage. Justin Hunter, the Tennessee Titan wide receiver was hit hard after an interception and returned to play. Only later was he taken from the field to the hospital, where he was diagnosed with a spleen injury.

This is often the case with blunt force trauma to the abdomen. It takes time for bleeding and swelling to reach a point where pain receptors are triggered and symptoms felt. Still, it takes a high index of suspicion to look for and find hidden injuries to abdominal organs.

The history of what trauma befell the victim is always helpful, especially when there is high velocity trauma involved, for example a car wreck or a fall from height. When the patient is in shock, (not the emotional “I can’t function” shock, but the “low blood pressure, fast heart rate, sweating, there isn’t enough blood being pumped to my organs” shock), the search for blood loss often starts in the abdomen and chest. Here is where ultrasound and CT scans have made diagnosing injuries quicker and more efficient.

Football is a violent sport but the hits are more often considered low velocity. Still, a helmet to the abdomen or the ribs can cause significant damage, but the injury is often caused by bruising or swelling and that takes time to develop. The spleen is located in the left upper quadrant of the abdomen just beneath the diaphragm, the muscle that separates the chest from the abdomen, and is protected by the lower ribs. A blow to that area can cause bleeding within the spleen; the associated swelling causes progressive pain. The symptoms may be confusing, since the swollen spleen can irritate the diaphragm and the victim may complain about referred pain to the shoulder (it’s how the pain fibers are wired; blame the design engineer). The spleen can also swell to irritate the stomach and the main complaint might be indigestion. It’s the physical exam that is important in deciding whether the abdomen feels as if there is a potential problem that needs aggressive intervention or whether it’s just an abdominal wall bruise. Clinical judgment is key, since not everybody who is hit in the belly needs a CT scan. On a tangent, the spleen swells below the protection of the ribs in patients with infectious mononucleosis and for that reason, those patients should not be involved in any activity when abdominal trauma is a possibility.

The kidneys are located in the flank, behind all the abdominal organs, in the retroperitoneal space and are almost protected by the ribs. Their location is important because an injured kidney will cause pain but may not cause inflammation of the peritoneum, the sac that contains the major abdominal organs. Peritonitis on physical exam often signals the need to look for problems inside the abdomen. Being hit in the flank or back is a helpful history, but as Mr. Austin found, sometimes, you don’t know when you got hurt. Having back pain is an occupational hazard for football players, but if the kidney has significant injury, blood can be seen in the urine. This is not a necessity, again because of a design flaw. The kidney floats in a pad of fat and is tethered to the body in two place, the first by the artery and vein that supply it with blood and the second by the ureter that drains urine to the bladder. If the kidney is torn away from the ureter, no blood may be seen on urinalysis. That said, the amount of blood in the urine is not necessarily related to the severity of the injury.

Fortunately, technology has become a great ally in the diagnosis and treatment of solid organ injuries. Ultrasound can screen for organ size and abnormal fluid or blood within the abdomen. CT scan is able to diagnose injury and its severity to help plan treatment options. And that treatment is no longer just surgery to remove a damaged organ. Often, the body can heal itself if given time and support, or if there is active bleeding, an interventional radiologist may be able to snake a coil into the damage artery and stop the bleeding.

Unfortunately, there are still many other potential abdominal injuries that like to hide and take even more time to develop, including duodenal hematoma or intestinal perforation or mesenteric tears. Think of an organ and the body can hide damage from it…at least for a while. For that reason, close observation of blunt abdominal trauma victims with repeated physical examination and blood testing is often the wisest course of action. On television with Chicago Hope, Gray’s Anatomy or House, all is resolved in 45 minutes plus commercials, but in the real world, observation and using time wisely to watch over the patient is critically important. Time is the ally in treating many patients and patience can be rewarded as symptoms progress and injuries declare themselves. Just ask Miles Austin and Justin Hunter.


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