Thursday, May 24, 2007

Iatrogenesis

Hail,
Lots to tell today, and not a huge amount of time before our first bit of disciplinary pharmacotherapy, so on with it.

First off - news from last week. Mrs Bishwakarma is still alive, gradually improving, and I suspect she will do well, from an acute medical point of view. Mr Graves died, surrounded by family. His heart went across the Nullabor, his kidneys and liver to Sydney. His blood type did not match Mrs Bishwakarma's.

Everybody lives, as Doctor Who said. All in all, good lives and good deaths. There are good feelings in ICU - sometimes you win. I thinnk that's part of what makes ICU and ED much easier on some level than the drug and alcohol work.

So - who have we been worrying about this week?

Well, for me, it's Mrs Quintain. Mrs Quintain is a woman who may have been killed by the care and affection and attentions of her doctor.

Here is the story. She went on a camping trip with her husband, daughter and grandchildren to Cape Irukanji, staying in a caravan park, fishing and prawning and doing crossword puzzles. Unfortunately, somewhere along the line she became unwell. Nausea, vomiting, diarrhoea, ongoing loss of weight. When you are sixty three, even a young sixty three, two weeks of that can knock you about a fair bit. When she came to see her doctor she had lost eight kilos* in a fortnight.

Her doctor was obviously concerned and did a remarkably thorough set of blood tests, Xrays and so on. One of the things he tested for - and it's certainly a consideration in a sixty three year old woman who smokes and has chronic loss of appetite, tiredness and nausea - was pancreatic cancer.

Pancreatic cancer is, as I have said several times here, one of the nastiest forms of cancer to get. Almost the only good thing to be said about it is you don't have it very long. Ninety five percent of people who have inoperable pancreatic cancer are dead within five years, most die within the year.

Anyhow. The doctor sent off the plethora of blood tests and did the scans and called Mrs Quintain in to discuss the results.

"You may have cancer" he said. "But I think we've caught it early. It didn't show up on the CTs, but the blood test is positive."

She was terrified, but followed his advice. The next stage was an endoscopic procedure - she would be sedated, a slim black tube with a camera in it would be slid down her throat, perhaps a dye would be squirted in to enable the physician to have a better look, and anything sinister would become clear. She went in for the endoscopy - the full name is an endoscopic retrograde cholangiopancreatography - three weeks ago.

It didn't go well. The tube tore a small hole in the lining of her gut. The bacteria-laden intestinal fluid leaked into what we call the peritoneum, the sac in which your guy and stomach and so forth float. Infection spread like a cloud. By the time she came to us she was barely able to mount a fever, her blood pressure was low, se was slipping in and out of consciousness.

That was three weeks ago. We pumped her full of our remarkably simple chemicals and got her well enough to get back to the surgical recovery ward. She did well for a few days, but then an astute intern noticed her breathing rate, and found that the amount of oxygen in her blood was low. A chest X-ray revealed pneumonia. She was sent back to the ICU.

We "fixed" that, by bludgeoning her with great scoops of weapons-grade antibiotics, and sent her back to the surgical ward. She'd been there sixteen hours when the code was called. At three in the morning they resuscitated her. A scan the next day - her fourth or fifth - showed a massive blood clot in the lung - despite the anti-clotting agents we had put her on.

"Never seen anything like it" Dr White said. "Massive thromboembolism on clexane. Not in twenty years."

So now she lies in the ICU, intubated, unconscious, on infusions of adrenaline and antibiotics. It's not looking good - infection in two places plus a sizeable blood clot, maybe brain damage from the resuscitation, a healing hole in her gut...

About the only thing that isn't wrong with her is pancreatic cancer.

I am not making this up. We have scanned every micrometre of this woman's body. Her pacreas has been visualised from every possible angle, scanned with sound waves and Xrays and magnetty things and whatever else we can come up with. I have more chance of having pancreatic cancer than she does.

Anyhow. The problem with blood tests and scans and everything else is that, like everything else, they can be wrong. Medical literature is alive with sotries of "false negatives" - tests that tell you you havent' got the disease when you have, and "false positives" - tests that say you've got the disease when you haven't. It's the same with every decision making process - trial by jury, speeding tickets, surfing internet dating sites. Pobodys nerfect. And obviously the more tests you order, the more results you get, the more likely it is that you one of them will be false.

So. If things go as they well might, who or what killed Mrs Quintain? Medical language, like the crypic speech of other gang members, is often designed to conceal rather than reveal meaning - Dr White had stood at Mrs Quintain's bed and spoke of the "mitotic lesion" a few days earlier. But there is one medical word that perfectly describes what happened to Mrs Quintain: iatrogenic.

Iatrogenic means caused by doctors. An un-neccesary blood test, poorly interpreted, an inadequate clinical history, a cascade of errors, some preventable, some not. In this case doctors have brought this woman almost to the threshold of death. If life is daylight, and death is night, she is in the twilight, the penumbra, and the light is fading. We have poisoned her, pierced her gut, given her pneumonia, shocked her heart. And we are not finished yet. Soon as she wakes up, we'll be on her again.

Anyhow. It may end up well. ICU does drag people back from the dead, even those we've dragged most of the way there in the first place. We shall see. But whether or not she survives this, I am going to sneak in and amend her adverse drug reactions status - the part where we doctors write what substances a patient is allergic to. Next to aspirin and penicillin and the sulfa drugs, I am going to write "doctors".

Thanks for litening,
John

Next post, by the way, may be about stupidity as a virtue.

*Two and a quarter pounds of jam/weigh about a kilogram.

4 Comments:

Blogger Benedict 16th said...

I prefer nosocomial* to iatorgenic** they are bloody dangerous places to be in!

Also I have had a success*** in the drug and alcohol field. B1 injections for 3 days in a row, and Joan Collins can now remember my name, when I show her a paper-clip she names it, she can do the serial sevens.... Last week she scores 11 on the MMSE, today 24!

Benedict

* nosocomial
** iatrogenic resulting from the activity of physicians****
*** okay, she is still drinking alcohol, she is still scarfing 50x5mg diazepam and 25x30mg oxazepam a week! but her Wenekce Korsacoff syndrome seems to be in abeyance! I'll take that as a victory.
**** physicians note the exclusion of surgeons

10:24 PM  
Blogger jenblanck said...

That is a terrifying, and sadly unsurprising story.

Juanita

11:20 PM  
Blogger Ozma said...

I guess the statistics on iatrogenic illnesses are pretty darn scary.

It is always interesting to have some minor-type ailment (in my case high TSH) and discover the doctors don't know what to do or they all think something different, etc. Your odds are way better with doctors and hospitals than without them but then you also have to accept that they might mess up and kill you.

12:58 PM  
Blogger Midwife with a Knife said...

It's amazing how easy it is to make a mildly ill patient very very ill.

7:43 AM  

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