Kevin Pho M.D. has written that a screening test incidentaloma can make healthy people ill.  This is a theme that appears too frequently in the medical literature. When I previously addressed this issue in a prior article it did not then occur to me that the argument might be used to impair patients receiving recommended screening.

Medicine constantly searches for safer more specific screening tests to permit early diagnosis of treatable, but otherwise deadly diseases. Before a new strategy is introduced generally or prescribed in the care of a particular patient, considerable thought has been given to the sensitivity and specificity and cost of the method. Complications associated with a particular method are considered. Complications associated with such follow-up as may be employed in the pursuit of false positives is very much a part of the process.  A nodule appearing on an imaging study doesn’t automatically require a biopsy or invasive form of follow-up.   The distinction between findings that require follow-up and the particular kind of follow-up required is a matter of ongoing study, and it should be.

Earlier I addressed the idiocy of ignoring unexpected findings made on a diagnostic study. Example: A chest x-ray is performed because pneumonia is suspected. The film when interpreted by the radiologist reveals a mass. Should one  ignore the mass since that is not what was expected? The same logic could be employed to ignore a mass seen on a CT scan of the brain performed because of a recent head trauma. What is common to this point of view is the assumption that a physician’s initial assessment represents the universe of possibilities.

We once believed the earth was flat. Knowledge is acquired when we put aside assumptions that stand in the way of recognizing what is real.

What do you think?

ANEMONA HARTOCOLLIS in a recent New York Times article describes outrageous behavior by the clinical director and medical director of Harlem medical center. Under the direction of these former hospital officers (they have since been fired and demoted,  respectively) the cardiology department of the Medical Center permitted 4,000 echocardiograms performed on patients suffering from suspected cardiac problems to be read only by technicians. The tests supposed to be read by cardiologists were not submitted to any doctor for review. An investigation  conducted by physicians from another medical center suggests hundreds of these patients may have suffered serious harm as a consequence of inadequately skilled technicians reviewing these tests instead of cardiologists.  In an apparent cost cutting move, Harlem Medical Center had allowed their staff of cardiologists to be reduced. The cardiologists claimed the back log of echocardiograms requiring physician review accumulated at the rate of 2500 per year. The Harlem Medical Center cardiologists’ cries for additional staff went unheeded.  Harlem Medical Center continues to deny that any patient suffered harm.

Certainly patients who trusted the Harlem Medical Center  have been betrayed. Can anyone believe that similar problems are not occurring with some frequency elsewhere? The only real oversight is limited help that medical malpractice lawyers can provide victims after the fact.  And yet trial lawyers are besieged in the Legislature of most states and by members of the Congress who are blind and deaf to the pleas of victims  to not restrict the only tool available to most victims to uncover the truth and seek justice.

What do you think?

January 1, 2010 Journal Watch summarizes a remarkable article entitled “Investigation of incidental findings on cardiac CT.”  The article was based on a study conducted at a Canadian institution where the investigators evaluated the incidence, clinical importance, and costs of these incidental findings.

It’s first important to note that these researchers used the word incidental as  equivalent to the word, occult.  In medical imaging, an occult finding is an unexpected finding that has clinical consequence.  Such findings are made with great frequency and have dramatically improved the lives of many.  For example, a chest x-ray searching for a rib fracture reveals a lung cancer mass which was otherwise completely unexpected.  A CT scan of the abdomen performed because of a complaint abdominal pain reveals a dissection of the thoracic aorta.

The Canadian researchers are strangely troubled by the discovery of   unexpected conditions.  The test they are evaluating is cardiac CT.  Imaging data obtained during a cardiac CT includes imaging information of structures or tissues outside the heart.  in an examination of 966 consecutive patients who underwent cardiac CT during 12 months at a single Canadian institution, incidental findings were noted in 401 patients.  12 of the patients were found to have clinically significant conditions, many of them, life-threatening without treatment.

Even if one accepts the very conservative assessment that only 12 of the patients were found to have clinically significant conditions,  that means that 3% of everyone who had a cardiac CT performed had a condition that might have seriously harmed or killed them if it had not been accidentally seen in this study.

The researchers do not see the benefit derived by the 3% as a bonus.  They don’t question that all the patients benefited from having a cardiac CT.  In fact, no one questions that this method of scanning provides an important and noninvasive method of evaluating patients suffering coronary calcification and arterial disease.  However, 68 patients exhibited incidental findings such as nodules or cysts in the lungs or liver.  There’s the rub.

Confronted with 68 patients of the 401 who had abnormalities deemed to be indeterminate (undetermined significance)  researchers worry that the abnormalities found might lead some to conduct further testing or evaluation.  The solution, as they see it, is to not format the data concerning non-cardiac tissue and structures.  They want to ask patients to consent to keeping the non-cardiac information invisible.  If they see no “evil”, they need speak no “evil.”

I think this is insanity. What do you think?

www.youtube.com/watch?v=48RUxC3zvH4

The mother heard speaking in the above ad was present when a teenage driver recklessly careened down a quiet street striking her young son.  The teen pulled into the nearby driveway of his home not even having realized he had hit and dragged the child.  Miraculously, the child had only suffered severe scrapes and bruises.

The child was promptly taken to an emergency department of a large teaching hospital where a thorough survey confirmed the child had suffered no head injury or internal injury and the family was relieved.   During the course of the various studies that were performed an endotracheal tube was inserted through the child’s mouth and into his airway to assure control over the child’s breathing should an, as yet, undetected injury to the lung or the space surrounding the lung be present.  Because the child naturally resisted having a tube in his throat and respirator breathing for him, the child was chemically paralyzed so that he could not interfere with the respirator breathing for him.  Though by end of day the tests were all negative the tube and respirator were left in place.

The child was transferred out of the emergency department to a monitored unit with the plan being that the tube and ventilator be removed the next morning.

That night, while a physician was teaching a less experienced resident physician to perform a procedure on the child the tubing connecting the respirator to the endotracheal tube in the child was unintentionally bumped by the doctors and the endotracheal tube was displaced such that the respirator was no longer ventilating the child.  This event went unrecognized because alarms on the ventilator designed to warn immediately and loudly of the occurrence of such an event had been turned off.  The disconnect was not therefore discovered until the child was virtually in cardiac arrest.  Though the child survived following resuscitation, brain injury which resulted from the tube displacement and ensuing respiratory failure left him initially comatose.

The child’s mom and dad though present in the hospital were not in their child’s room when this catastrophe occurred.  When they saw their son the next day they weren’t alarmed that he wasn’t moving because they knew he was chemically paralyzed.  Excuses were given for why the child wasn’t removed from the ventilator that day and required continuation of the paralytic drugs for another day or so.  Then the paralytic drugs were removed and the child was successfully able to be removed from the ventilator and have his endotracheal tube removed and he breathed on his own.  He did not however wake up until much later.

Doctors provided the family with no explanation for why their child who had been admitted for bumps and bruises was now in coma.  The delayed resuscitation of their child and the physicians’ role in unintentionally displacing the endotracheal tube was not disclosed.

These unique circumstances led the parents to contact a lawyer.  I had the privilege of being the lawyer who was contacted.  My investigation revealed that the child had an unexplained need for a resuscitation because of an allegedly sudden drop of oxygen levels in his blood which coincidentally occurred at the same time that the child’s endotracheal tube suddenly became displaced for no particular reason.  Being a former respiratory therapist who had worked with respirator-dependent patients for many years, I was well aware that, in this child who had no lung disease or lung injury, there would not have been any sudden drop in his oxygen level from a displacement of an endotracheal tube because such a displacement would be immediately recognized if the alarms were properly set.

Eventually, I was able to discover and establish that the airway accident was easily avoided and that improper monitoring had led to such a delay in the recognition that a tube displacement had occurred.  The child was needlessly suffocated and anoxic brain damage had occurred.

Because of requirements of confidentiality imposed by a state agency on all medical malpractice cases, I am unable to report the means by which I was able to discover and prove the truth.  Similar confidentially requirements also prevent me from reporting the method or means by which we were able to help this child and his family meet the many economic and other challenges they faced.

This story is just one of many such stories untold.  Regrettably, because so many of these stories are untold, many victims of malpractice are unaware of what happens and where it happens and that it happens in every hospital.

When unexpected tragedies occur and doctors have inadequate or suspicious explanations, an experienced lawyer may be the only way victims can ever discover the truth.  By then taking action victims are no longer powerless.  Indeed, they help make the healthcare system better.  After all, you cannot fix something you don’t think is broken.

The Archives of Internal Medicine, June 22, 2009, published results of a retrospective medical record review involving nineteen community based and four academic medical center primary care practices.  The researchers were intent upon examining how frequently patients were not informed of clinically significant abnormal outpatient test results.  The researcher’s conclusion was that it is common for patients to be uninformed of significant abnormal outpatient test results and they suggest a simple process currently not being followed by most primary caregivers to correct what the researchers see as a problem.

Remarkably, they fail to comment on an additional meaningful conclusion that can be arrived at from examining the same data.  The doctors who didn’t inform their patients must not have done anything about the abnormal lab results.  Surely, it is not possible that physicians failed to inform patients of significant abnormal lab results only in cases where the lab results, though abnormal, suggested no need for a different course of medical treatment.  Perhaps a more important issue for these researchers to have examined is whether the results were communicated to the doctor and whether the doctor incorporated those results in the formulation of each patient’s continued and future course of care.

In these circumstances, a patient’s safeguard of last resort is their own interest in their medical care.  Patients need to be attentive not just in the outpatient setting but also in the hospital setting.  A patient should not assume that because there are a number of people who seem involved in their care, doctors, nurses, etc., that someone in fact is aware of all clinical events and test results and is thoughtfully guiding the patient’s care with a professional interest in the best possible outcome.

Learn more about abnormal pap smears.

According to Alan Mozes’ report, Monday October 10 in Health Day Reporter, a new study suggests more than 12 percent of cancer patients in the U.S. are undiagnosed initially. Apparently this leads to treatment delays and lost opportunities for better outcomes.

The study was conducted by a team of researchers from Canada, China and the United States but based upon the experience of four American medical centers.

Study author Dr. Stephen S. Raab, a professor of pathology at the University of Pittsburgh School of Medicine said “I want to make clear that the major consequence is not that patients unnecessarily have organs removed or have a false diagnosis of cancer, but rather that they have cancer and it is not diagnosed.”

This study provides insight concerning the accuracy of cancer diagnosis nationwide. The researchers estimate by extrapolation that about 150,000 cancer patients who undergo Pap tests annually may be subject to such mistakes. If the probability of error in cancer testing applies, as these researchers suspect, across the broad spectrum of cancer diagnosis, then surely many patients needlessly suffer from delay.

For more information abnormal pap smears

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).

MGUS is not multiple myeloma. There are distinguished physicians who write ably and in detail about the differences. It is however also the case that if a person has evidence of MGUS 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 MGUS 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  a neck bone (cervical vertebra).  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.

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 health care 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.