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Thursday, June 05, 2008
MUGUS (Monoclonal Gammopathy of Undetermined Significance)
Each year many die of multiple myeloma. It is a cancer principally affecting bone but capable of metastasizing to the lung and soft tissue. A man or woman in their 40’s or 50’s suddenly suffering a fracture of some spinal element without any precedent trauma that they can recall is certainly a possible victim of this disease. Other primary bone cancers and infection are also possibilities.
In such setting, physicians often will perform a test called Protein Urine Electrophoresis. This test is calculated to determine the presence in the urine of light chain protein. It is not very important that one understand what a light chain protein is. It is important to understand that kidneys are not supposed to leak proteins and if they do leak proteins, it is a distinct possibility that a light chain protein is involved (also sometimes referred to as M proteins).
MUGUS is not multiple myeloma. There are distinguished physicians who write ablely and in detail about the differences. It is however also the case that if a person has evidence of MUGUS and they live long enough, they suffer a one in four chances of dying of multiple myeloma, a terrible illness.
It is for this reason that it is worthwhile to be screened by urine electrophoresis testing any time there is an unexplained fracture.
There are some who follow MUGUS simply by doing regular screening to determine whether the concentration of protein increases or not. These physicians will argue that there is no reliable evidence that treating multiple myeloma prior to its full-blown appearance does no good. On the other hand, if one doesn’t carefully monitor for this cancer by the time a diagnosis is made it is entirely possible that one will be suffering several crushed vertebrae with metastasis and other dreadful consequences. A delay in diagnosis worsens the outcome.
A client of ours once suffered a fracture while playing golf. He did not fall or strike himself. The fracture was of the neck bone. An intern appropriately considered the possibility that this unusual fracture without trauma might be due to osteomyelitis or some form of cancer such as multiple myeloma. Among the tests that were ordered was the urine protein electrophoresis examination. The test was positive but was reported to no one.
It is essential when you are in the hospital for a workup for any illness that you take active steps to learn whether all lab results and imaging results have in fact been directly communicated to persons with an interest in your health. A mistake in communication can have disastrous consequences.
posted by Jerry Meyers at 12:47 PM
Tuesday, May 27, 2008
Anesthesia error leads to woman's death
Communication is essential between health care providers but sometimes communication fails because of the arrogance or carelessness of the persons involved in the needed medical communication.
Several years ago, a female client about to enjoy an important anniversary was admitted to a University affiliated hospital for the purpose of having a colostomy wound debrided (cleaned up).
This was to be a one-day inpatient hospital procedure and was associated with little to no risk. It was, of course, a part of the procedure, however that an antibiotic be administered to the patient at the time of the procedure to protect against the possibility of some subsequent infection.
Unfortunately in this particular case, when the antibiotic was administered the patient suffered a sudden cardiac arrest. This cardiac arrest resulted from a rare but well-known allergic reaction to a particular antibiotic. The patient was successfully resuscitated. No harm done.
Because the patient suffered a cardiac arrest before her surgery could be performed, she rescheduled the procedure to occur approximately thirty days later with the same surgeon who had earlier been involved. Though the anesthesiologist who had saved this patient’s life earlier recorded in the order sheet, in the progress notes and even in a typed signed note provided to the patient notice of what had happened to her, “You are allergic to the drug Cefotan. Don’t allow this drug to be administered to you. You may die.” Who could have done more to protect the patient from a similar future occurrence?
The patient showed her surgeon the note her anesthesiologist had provided and rather than openly disagreeing with the note he simply said he was aware of that.
Thirty days after the patient’s original cardiac arrest she was readmitted for a repeat of the same procedure that was originally planned. The patient had ugly premonitions about what might happen which she shared with the admitting nurse. The admitting nurse was sufficiently concerned that she assured the patient that an anesthesiologist would attend the patient before the patient went to the operating room to ease the patient’s mind. The anesthesiologist who came to the patient’s side assured the patient that everyone knew she was allergic to Cefotan. "You will not receive Cefotan." Were she to receive Cefotan she might die. The wristband the patient was wearing revealed the presence of this infection as did numerous references in the hospital records that no one could possibly miss. The anesthesiologist promised the patient, "You will not receive this drug."
Notwithstanding all these assurances the patient went to the operating room for her one-day procedure and as the same anesthesiologist entered the room who had just offered such reassuring promises, this anesthesiologist observed the patient was about to receive a prophylactic antibiotic intravenously. The anesthesiologist promptly inquired as to the type of antibiotic and was told, "Well its antibiotic Cefotan." "But she is allergic to that."
Amazing, the surgeon present who was the same surgeon present at the time of the original cardiac arrest insisted that the patient get the prophylactic antibiotic and the anesthesiologist present and the nurse anesthetist present lacked the courage to refuse. The drug was administered. The patient died.
These facts are taken from a real case. Agreements and legal restrictions prevent the identification of names and places or even institutions.
The case was concluded in such a way that all involved were aware of their involvement and what they did, how it contributed to the patient’s death and what should have been done otherwise. It is not always possible to prevent malpractice before it occurs but it is certainly essential to see to it when it has occurred with unfortunate results that those involved are made aware of what they have done and with what consequence. It is the least we can do to assure that it is less likely the catastrophe be repeated.
posted by Jerry Meyers at 7:15 PM
Monday, May 12, 2008
Hospital Acquired Infections
According to the CDC 99,000 people die annually from hospital-acquired infections. As Betsy McCaughey Ross, the former Lieutenant Governor of New York put it, “You don’t often come across such a big problem that you can prevent.” McCaughey started the committee to reduce infection deaths in New York.
In Pennsylvania we suffer similar problems from hospital-acquired infections. The problem is two fold. First the communication of infection from patient to patient through contacts with healthcare providers and visitors results in a large proportion of people needlessly being infected.
More importantly, however, needless infections rarely have permanent or devastating results if the presence of infection is promptly recognized and properly treated. It is in general wrong to await the treatment of an infection until you have identified the specific organism involved. Once it is recognized that there is a potential infection in a part of the body, whether in the soft tissue, lung, urinary tract or elsewhere, waiting for results of cultures that identify the specific organism involved is entirely unnecessary. Instead, immediately after a specimen of potentially infected material has been obtained for culture analysis an appropriate antibiotic should be selected based on those organisms most often afflicting the organ or tissue involved. In addition, antibiotic should be selected with a broad enough coverage spectrum that a wide spectrum of different organisms that might be causing infection will be effectively controlled. The antibiotic initially chosen can be changed if clinical improvement does not occur or if culture results (sometimes not available for days) suggest a different drug is indicated.
In the case of surgical wounds, redness, warmth, swelling and pain are all signs of a potentially infected wound. In addition fever, chills and night sweats are further often late signs of infection. Antibiotics may be inadequate to address a particular infection even if they are appropriate to the bacteria involved. This is because sometimes the infection becomes associated with a collection of bacteria and pus, an abscess, which requires surgical drainage in order for antibiotics to be effective. Moreover, abscesses once formed in the abdomen, soft tissue or elsewhere can seed bacteria into the blood causing bacteremia leading to septic shock and death. Since many infectious deaths are preventable, it is tragic that so little effort is employed in hospital systems to identify those suffering permanent injury or dying from preventable or earlier treatable infections.
In this firm we have examined countless cases of patients having suffered adverse consequences from infections. It is often the case that the patient’s infection in the first instance was not preventable. It is very difficult to show that a particular infection was acquired because of breaks in sterile technique by hospital personnel. Patients in hospitals are susceptible to infection because they are often ill. Anytime surgery has been performed the surrounding tissue has an impaired ability to resist the consequences of infection.
It is for this reason that it is so important that signs of infection are rapidly recognized and reacted to.
Persons whose lives have been lost or have suffered debilitating catastrophic injury as a consequence of delay in the diagnosis and proper treatment of an infection have been assisted by our office on many occasions. Serious injury and death following infection therefore always justifies an inquiry as to whether there was a timely and proper response to the signs of infection that may have been present.
Quite often it is the case for various reasons that an infection grows to have grave consequences in spite of the fact that it is recognized and properly treated. Even in these circumstances it is typical that doctors and nurses involved in the care of the patient inadequately explain to the survivors and family the course which led to the unfortunate result. We have served hundreds of families in relieving doubts concerning whether a very bad result was preventable or not. Though these end up being families we don’t represent, we nevertheless serve them and are grateful to have the opportunity to bring them to an understanding of what otherwise might have been a life-long matter of concern.
posted by Jerry Meyers at 2:49 PM
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The Pittsburgh, Pennsylvania attorneys at the law office of Meyers Kenrick Giuffre & Evans, LLC focus on medical malpractice and personal injury cases
in the following cities and counties in Western and Central Pennsylvania: Allegheny,
Altoona, Armstrong,
Beaver County, Blair County,
Butler, Cambria,
Clarion, Clearfield,
Crawford, Elk, Erie,
Fayette, Indiana,
Jefferson, Lawrence, McKean,
Mercer, Somerset, Venango, Warren,
Washington, and Westmoreland.
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