|Home | About | Journals | Submit | Contact Us | Français|
In mourning the demise of bedside skills, I derive solace from colleagues who share my grief. One of those colleagues is Dr. Martin Grais, Associate Professor of Clinical Medicine, Division of Cardiology, Northwestern Feinberg School of Medicine in Chicago. Marty recently sent me the following note by e-mail:
You have written much about the importance of bedside skills. Do you think the journal you've been writing for might publish a case that I would write up and you would discuss? The object would be to show that advanced technology is much overused and that ordinary clinical skills are sufficient to diagnose and manage most illnesses. Here, for example, is a case rich with possibilities for discussion:
About 20 years ago, a 78-year-old woman left her hotel in downtown Chicago to mail a letter. On returning to the hotel, she was beaten and raped by a predator who subsequently that same evening was caught attempting to attack another woman at an adjacent hotel. The initial victim was taken to our emergency department, where she was found to have bilateral fractures of her mandible with a flail jaw and unsupported tongue, raising the risk of respiratory obstruction and requiring urgent surgical repair. Because her preoperative electrocardiogram showed mild, diffuse, nonspecific repolarization changes, a cardiology consultation was requested.
I responded promptly. Her history was unremarkable for cardiovascular disease, and her physical examination was normal except for the fractured jaw and a small area of almost inapparent ecchymosis over her sternum. The ecchymosis had not been noticed previously and might not have been present at admission. Nevertheless, I had found it because I was looking for evidence of chest injury that might explain her abnormal electrocardiogram.
Her chest radiograph was reported as normal, but I went to the radiology department to review it with a staff radiologist. I asked him to pay particular attention to the sternum. Sure enough, he found a sternal fracture. Knowing that the descending coronary artery lay just beneath the sternal fracture, I thought that the vessel might have been contused during the beating. The contusion, in turn, could have led to a clot or spasm of the vessel or to rupture of a pre-existing plaque. Alternatively, contusion of the heart itself or traumatic pericarditis could have caused the electrocardiographic changes, but there was no pericardial friction rub or elevation of the S-T segments.
Since the patient would have died from respiratory obstruction without urgent surgical intervention, there was no point in postponing the operation to do a cardiac catheterization. Consequently, I spoke at length and in detail with the patient and her family about the possibility of a perioperative cardiac event. I told them that, in my opinion, we could reduce her risk by controlling her heart rate and blood pressure. I also favored the use of a β-blocker preoperatively.
Although the surgical procedure went well, postoperative serum enzymes revealed a small, clinically mild myocardial infarction from which the patient recovered without sequelae. A year later, she sued the hotel for lack of security, and I was asked to give a deposition regarding the cause of her perioperative myocardial infarction. I attributed her infarction to the chest injury and said that without the injury and subsequent need for surgical intervention, the infarction probably would not have occurred. The court ultimately awarded the patient several million dollars. (Incidentally, my fee for the initial consultation, 2 weeks of hospital care, and the deposition totaled $1,000. I suspect that her lawyer got much more.)
Moral: Absence of proof is not proof of absence. Just because an X-ray report does not describe a fracture doesn't mean that there is no fracture.
I replied as follows:
Congratulations. Your care of that patient was exemplary. To begin with, you responded promptly to the call for consultation. That's the way all consultants should respond, but not all do.
Second, you found what you were looking for (the sternal ecchymosis), not what you were necessarily looking at. If we don't know what to look for, we're not apt to find it, even when we are looking directly at it.
Third, you personally reviewed the patient's chest radiograph with a staff radiologist. In doing so, you provided him with reason to look for a specific, localized abnormality—something that the X-ray request form did not, and ordinarily does not, provide. Given that added information, the radiologist was able to detect an important abnormality that had been overlooked. Unfortunately, practitioners no longer make it a habit to go to the radiology department to review images of their patients with the radiologist. They should.
Fourth, you sat down with the patient and her family to do what many doctors fail to do—explain in detail and in understandable language the medical issues involved, the therapeutic options available, and the various potential outcomes.
Finally, as your fee for service showed, you put your patient first—above personal gain. That, of course, is the guiding principle of our profession.
Keep up the cause,
Marty responded rapidly.
If you liked the first case, you should love this one:
I teach physical diagnosis to sophomore medical students. The other day, all 4 of my students easily felt the enlarged liver of a middle-aged woman with known cirrhosis. They also easily felt the edge of her spleen at the level of the umbilicus. One of the students said, “Since the CT and MRI show her spleen to be normal in size, what are we feeling?” I told him that he and the other 3 students were feeling the spleen and that we should all go to the radiology department to review the aforementioned images with a radiologist. There we found, on cross-sectional view of the abdomen on both the MRI and CT studies, that the spleen measured 7 × 7 cm—normal in size. However, the coronal view on the MRI revealed a huge, 19-cm-long spleen with its edge where we had felt it on physical examination. The radiologist acknowledged that, for some reason, the coronal view had not been included in the MRI report; that view was not part of the CT study. We then called the attending physician with this new information so that it could be applied to the patient's care. The patient, in fact, had pancytopenia and most likely hypersplenism. To prevent future examiners from believing that the spleen was normal in size, we asked the radiologist to submit an addendum to the original MRI report, reflecting the presence of profound splenomegaly.
Later, we learned that this woman had been examined in our emergency department or as an inpatient at least a dozen times in the past few years. Yet no one had described her spleen as being enlarged, presumably because several MRI and CT studies had been reported to show a normal-sized spleen.
This case illustrates the value of correlating the findings from physical examination with those from an imaging study, rather than simply deferring to the imaging study. It also demonstrates again the value of reviewing imaging studies face-to-face with the radiologist.
I look forward to your comments.
This time, I had little to add.
Accepting an imaging report as gospel is the rule these days. There are several reasons for this mistake. The diagnostic capability of advanced technology is so accurate in so many situations that we rarely question the results. In fact, many physicians use MRI and CT in place of the history and physical examination. As a consequence, clinical skills have deteriorated markedly, making it difficult to challenge an imaging report. Even more important, many physicians do not use or rely on the most sophisticated machine always available to them—the brain.
In closing, I offer you an article* that I wrote in 1988 about a member of my immediate family who had a seemingly serious illness.1 Fortunately, the bedside skills of a consultant in that case were responsible for making the correct diagnosis, improving the original prognosis, eliminating further suffering, and saving a large amount of time, effort, and money. Here is the article verbatim:
The message from my wife was clear: “There's something wrong with Greg's neck. Come home now.”
As usual, Greg—our 6-year-old—was waiting for me at the back door. But this time, he didn't jump up for his hug. He couldn't. He was holding his head down and to the left. If he tried to move it or I tried to touch it, he would cry out in pain.
In retrospect, Greg had been irritable and less active for a few weeks, and his neck had seemed a little stiff. The acute pain, however, was new. His gait, too, was different—shuffling and unsteady.
Fearing the worst, I took Greg directly to his doctor. After quizzing me and examining Greg, the doctor listed as possibilities degenerative disease of the spinal cord, ruptured cervical disk, cervical arthritis, and cancer of the spine. He believed that the specific cause had to be identified and treated promptly. Otherwise, incapacitating, irreversible neurologic complications might ensue. He therefore urged immediate neurosurgical consultation.
An hour later, I was talking by phone with a neurosurgeon. On hearing the story, he recommended sedation, immobilization, pain medication, and a myelogram. He thought that an operation on Greg's neck might become necessary.
The seriousness of the matter persuaded me to take Greg to the university medical center 100 miles away. There I could receive additional opinions, and if surgical intervention did prove necessary, Greg would have a team of specialists to care for him—advantages not available locally.
When we arrived at the university outpatient clinic, a student and the chief surgical resident met us. They befriended Greg while I filled out an extensive form detailing his medical history. Next, they gave him an impressively thorough physical examination. The chief resident then called in the Professor of Neurology/Neurosurgery, Dr. Patricia Luttgen.
She assessed the situation and examined Greg. “Dr. Fred,” she said, “I suggest that you leave Greg with us for a few days. I promise to watch him carefully. We may do a myelogram tomorrow, but we won't do anything else without your knowledge and approval. I'll keep you apprised of Greg's progress and call you when I've reached a conclusion.”
Dr. Luttgen's call brought good news—news that was startling, and somewhat embarrassing. Greg was fine! His neck and gait were normal. In fact, he had run tirelessly and painlessly in a field, playing ball with Dr. Luttgen. He also seemed pleased by all of the affection that the students and house officers had shown him. And he had undergone no testing aside from a routine blood count and urinalysis. No myelogram, no operation.
When my wife and I came to pick up our youngster, Dr. Luttgen told us that his problem was loneliness. Holding his neck in a strange position and intermittently crying out in pain was his way of gaining the attention and love that he wasn't getting.
Everything made sense, especially when I saw the improvement in Greg's appearance and attitude. Tincture of time and love had done wonders for him. I couldn't help but think what might have happened had I not decided to seek help from the College of Veterinary Medicine at Texas A&M University. For if you haven't guessed, Greg is our Doberman Pinscher.
Baron von Gregory is 9 years old now. Since his hospitalization, he occasionally holds his neck down, whines, and begins to wobble. But if we give him an extra hug, tell him how much we love him, or give him a bone, those manifestations vanish.
The way the veterinarians at Texas A&M University handled Greg is the way we physicians ought to handle our patients—take a good history, do a pertinent physical examination, and then think a bit. That's always safer, and cheaper, than jumping immediately to a lot of tests. In that light, Greg's total bill for 5 days in the hospital was an incredible $107. And that included the professional fees!
This story exemplifies the medical value of what I call Milton's law2: “They also serve who only stand and wait.”3 Indeed, by standing and waiting, Dr. Luttgen and her associates served Greg well—they gave him a new “leash” on life.
So long for now,
*Reprinted by permission of Wolters Kluwer/Lippincott Williams & Wilkens. ©1988 Southern Medical Journal.
Address for reprints: Herbert L. Fred, MD, MACP, 8181 Fannin St., Suite 316, Houston, TX 77054