Monday, October 24, 2005

Suxamethonium doesn't kill people, doctors with suxamethonium kill people

Apparently this has happened upstairs, although details are lacking at the moment.

The patient was elderly, and there may have been some rare genetic thing involved, but I don't know. We don't have all the information as yet. This is hideous news.

Hope things go as well as they can do, under the circumstances.

The accused is one of the smarter doctors I know. Movie-star good looks, dark hair, dark eyes, speaks three languages, top of her class and friendly as well - although terrifying when she turns the full force of her intellect upon you, so you feel like an ant looking up through a magnifying glass and seeing the sun.

So - howabout the topic for today is doctors and getting sued - the fear of the law. Lawyers and legolophobia*.

My intercourse with the law has been very limited. A few times pulled over by the police in my younger days. The four hour stretch in what may have been the East Fremantle lockup years ago. Appearing before the judge to explain why the car I was driving was not registered. Nothing for ten years or more.

(Oddly enough, I have always found the idea of lawyers very sexy. I have no idea what that means, especially since the other career choices I find remarkably erotic are doctors and librarians - and women who work in bookshops. Seriously, I feel that those professions have more than their fair share of remarkably hot looking people.... Maybe it's some thing I have for that repressed looking, restrained, pent up sexuality kind of look. "Geek love is strong love", that kind of thing.

Or maybe it's because I find words and books and brains intrinsically hot.

You know, I have books that themselves are objects of almost erotic desire - the smell of them, the way they fit in your hand, the soft, cream-coloured pages, the gentle, firm curve of the page, the valley between where the words join the spine.

Good God. That should get me arrested next time I go to Borders).

But anyway. Doctors and the fear of the law.

The threat of prosecution or other legal action is meant to be something that haunts doctors, and I do see a lot of the fear in the ED. One of the consultants here, a deeply decent and very competent woman, saw a man (short, stocky, fifties) a few days ago who had left sided abdominal pain. He said it was like his kidney stones, he had had multiple attacks of kidney stones, he had pretty much nothing else wrong with him. He responded to the treatment for kidney stones, as he always had, and went on his way rejoicing.

And two days later the police rang up Dr Lazar and said that her patient had been found dead twelve hours after discharge, and that's a coroner's case, so that's what she's got to look forward to.

What everyone is thinking of is whether this man had a "triple A" or not. This is not the name of some Australian professional wrestler, it's when the big artery from your heart to the rest of your body swells up and then bursts (and you die): an abdominal aortic aneurysm. Once the swelling starts, you need urgent vascular surgery, ambulance to the Royal with lights and sirens, that kind of thing.

Weirdly, if you've been stabbed or are having a heart attack (each of which are usually more survivable than a triple A), we send an emergency doctor in the back of the ambulance with you. If it's a AAA swelling up we don't bother - because if it pops in the back of the ambulance it's all over. Nobody can help you.

Doctors can identify AAAs by feeling for them (put your hands side by side, fingers together, a few centimetres apart, in the midline between your belly button and your breastbone - if you feel something pulsating you're (very likely) admirably slim, or that's a triple A. This guy, unfortunately, was too fat for us to feel anything.

The other way of identifying it is by the symptoms - which closely resemble those of kidney stones. Or you can pick it up by a CT scan. The question everyone is owndering about all this is is whether and how recently this guy had been scanned, and thus who should we scan and how often should we scan them.

Anyway, how does this relate to lawyers?

There is a tension in medicine between good medicine and what we call defensive medicine. Good medicine (in the sense in whihc I'm using it) is what's good for the patient, defensive medicine is what's good for the doctor. Good medicine stops patients getting worse and defensive medicine stops doctors getting sued.

Thing is, you'd think that these whould be the same thing. What's good for the patient should be good for the doctor, we're on the same side, after all. If you make the patients better you shouldn't get sued.

But the thing is there is a difference.

It's most apparent in the case of "investigations": blood tests, Xrays, scans, that kind of thing. In an ideal world, with ideal investigations, all patients would be fully investigated: they would turn up, we would use (insert amazing technology here) to know exactly what's wrong with them, and proceed accordingly. Everyone would be happy.

But in the real world, investigations have costs: they cost money, which would otherwise go on more hospital beds, or vital research, or producing pamphlets and posters telling Australians to look out for anyone suspicious-looking. Investigations cost money. Someone has to pay for these things.

And investigations cause complications. Maybe I take your blood and you get an infection or a blood clot. Maybe the CT scan gives you cancer. And even if they are cheap and safe, often they don't tell us the right thing anyway - usually I don't Xray people who may have broken ribs, because chest Xrays are notoriously crap at seeing broken ribs, and if we can't see the broken ribs it doesn't mean they aren't there. If I reckon they've got broken ribs, I just treat them for it.

Here's another example. Ovarian cancer. This is a truly terrible disease. It kills four Australian women a day.... mostly because by the time anyone knows it's there, it's often too late. The symptoms are terrifyingly vague - abdominal or pelvic pain, vaginal bleeding, bloating, abdominal distension, irregular menses... and by the time anyone knows it's there, the surgery required is substantial, the chemotherapy aggressive, the outlook poor (although a damn lot better than a decade ago).

With that in mind, what kind of doctor would not offer his patients a blood test for tumour marker CA125, a substance that is often elevated in the blood of ovarian cancer patients long before symptoms are noticed, that can be rapidly and reliably detected from a few millilitres of blood?

Well, me, and pretty much anyone I know or know of. Because the investigation in this case is unreliable - it misses cancers that are there, it picks up ones that aren't. And if you do the blood test, and it comes back good, but it turns out you do have cancer - what then? Or what if you get an ominous result on the blood test - then you have to have surgery to find out what's going on, and often it turns out you had the surgery but there was no cancer, the test "was wrong". And gynaecological surgery is not without complications.

So what do you do? At the moment there isn't really a satisfactory method for screening people for ovarian cancer, nothing as good as, say, alphafetoprotein is for screening for Downs Syndrome and spina bifida in utero, or Pap smears** are for cervical cancer. Current practice is looking at some combination of a number of tumour markets, trans-vaginal ultrasound (yep, just what it sounds like) and so on.

Anyway - what does this have to do with good or defensive medicine? What do I do if I'm a general practitioner/family doctor sitting behind my desk and someone comes to me and wants the blood test? It's a huge issue - I have to help them understand what the test can do, what it can't, what it will mean if it comes back "positive", what the surgery can and can't do, what if the surgery goes wrong... it's vast. And it's different for every person. And the patient goes in there asking about cancer and comes out with soundbites like "13.7% chance of a false negative".

And this is all good. This is what I reckon medicine should be about - it should be about helping people make choices, giving them the information in a way they can deal with and to the extent that they can make sense of it.

But with defensive medicine, there's this whole undercurrent, this thing that goes through your mind at the same time, that when you look at it really has bugger all to do with the patient and what's best for them:

Scene: South Mordor Family Practice. Hassled looking man with stethoscope sits gnawing his phalanges behind a desk. Across the desk is a slim, worried looking woman gnawing her own phalanges.

Doctor (internal dialogue): Christ, she's asking for this bullshit test. She's twenty two, no family history, no symptoms at all - what are the odds? I'll recommend against it

... but what if she has got cancer? she's frightened, she's come to me for help... and I've told her not to have the test? I'm dead. Front page of the Sackbutt.

May's well do the test, that guy down the road'll do it if I don't. So we do the test... it'll come back normal, she'll piss off...

...of course, I'm even more screwed then if she has got cancer, because 'I told her everything was alright'. Front page of the Sackbutt, seven oclock news

...Maybe I should get her to come back in six months for a checkup, another test - Hold on, what am I thinking? Giving her two bullshit blood tests instead of one?

And if I do the blood test, and it comes back high - we're all doomed. She has to have surgery. Surgery for something she quite possibly doesn't have. And gynae surgery is bloody nasty. And there was that woman I sent off to the Royal last year, got MRSA, that's done me no end of good, still paying that one off. Didn't that guy Benedict sent in get a blood clot, dropped dead two days after discharge? Surgeon's fault, of course, not Ben's, but he has to deal with the family.

DOctor nods head, tries to look thoughtful, stares down at new paroxetine pen, suddenly has an insight. Diagnoses woman with anxiety disorder, starts her on paroxetine, sends her away. Everyone is happy.

Thanks for listening,

All this, by the way, is only relevant to screening - ubertests we do on vast numbers of people who aren't particularly symptomatic or at risk, but in whom we want to catch the disease before it starts. If you have symptoms, if you have any sort of family history, then limitations on screening are't relevant to you, see your doctor now.

* A terror of woodland elves - hahahahahahahhhaahaaaaaa!

**Pap smears, by the way, may be on the way out. There's a vaccine in the works, very promising stuff in a largeish trial, and the entire disease of cervical cancer may be getting a good kicking in the next few years. So, any over-eighteens who have ever had sex and haven't had one in the last two years rush off and get one now, before you miss out forever.


Blogger Benedict 16th said...

Sexy - Lawyers and Librarians, what about Legal Librarians - Look out Foilwoman!
Just don't tell her she reminds you of Allie McBeal unless you really like S&M...

And regarding your book fetish - but don't the pages all stick together after a while?

As for an AAA, I had a guy come in with back pain the other day after lifting a lawnmower into the boot of his car, I sent him to the physio. Two days later he saw the physio, who sent him back because he developed some abdominal pain (at the front). When telling another doc (Caro) this story, she asked "so what did you feel?", I said it went "boom-titty boom" ... I told him to go to hospital, do not pass go etc.. and asked him to phone his wife, who offered to pick him up. He said he would drive home for his PJs first then she could take him in. At this point I put my fingers in my ears muttering something like "I'm not hearing this!". Anyway I phone the hospital* ED saying he was coming in, that was about 5pm. I phone the hospital again 9pm, nope still hadn't been seen (I start doubting my diagnosis), try again 12pm "Oh the doctor has just picked up the chart now" said the triage nurse. Next morning a fax from the GSSMC said "AAA Admitted 12:12 AM, discharged to Shipman Private 12:24 AM". Must have been a priority 3?!

He had surgery about 9am next morning and home 2 days later.

He wanted to go to a private ED initially. Given he had just the aneurysm, that it didn't appear to be leaking as there were no peritoneal signs, just a fucking great, extremely tender palpating mass under his belly button, I really should have let him go The Wake.

* The Greater Southern Shipman Memorial Centre**
** THe GSSMC is the ED recently that a GP sent an 87 yo with acute bowel obstruction by priority 1 ambo, they were then was left in the ED for 2 hours before expiring!

9:04 PM  
Blogger Foilwoman said...

Yeah, I'm the epitome of hotness: former lawyer, former librarian, soon to be law librarian. If only I had all my limbs.

2:22 AM  
Blogger Benedict 16th said...

Re the pap smears
check out Mike Lascelles

from his blog:
Cervical cancer vaccine - how much is hype?

Pharaceutical marketing executives are salivating at the thought of a new $4 billion market for cervical cancer vaccines. They are one of the few possible blockbuster products on the horizon for the next decade. We have heard recently about how Merck and GSK's HPV vaccines are "100% effective", but what is the reality? Well, now the euphoria has died down, even the Australian inventor of the vaccine, Prof Ian Frazer, is adding a bit of his Scottish caution to all the hype.

What the experts are saying is that the following points have been overlooked in all the media overkill:

* The vaccines will only prevent 60-80% of cancer-causing HPV infections. There will still be 20-40% of cancers not prevented.

* The vaccine will only work on young girls who have not yet been affected by HPV - so no benefit for most women who have already been exposed to HPV.

* The vaccine may only be short lived - evidence is only in for five years. And if you need boosters, why not simplyrely on regular Pap smears instead of regular [and much more expnsive] vaccinations?

10:05 PM  
Blogger Bronze John said...

Bugger bugger shit. And it was such good hype, too. This is what comes from reading the opinion pieces rather than the sources.

Good blog though.

6:30 AM  
Blogger Bronze John said...

Well, you've clearly got all your brain cells, that puts you a fair run ahead of most people I meet.


6:31 AM  

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