American Medicine

I wish I had a copy of this in my pocket when asked about american healthcare by my Italian companions last week.  Its sad because its true.  Looks like we as a country need a refresheron LAW 13The delivery of good medical care is to do as much nothing as possible.

From ER Stories

OK, so you have an 86 year old lady. Mostly pretty healthy. A little HTN, and little high cholesterol. Quit smoking many years ago. You get a routine chest xray because she had a mild cough for a few days. You see several very small (about 1/2 a cm) nodules in the lungs. Now what do you do?

Choice A is what a reasonable person/MD would do and consists of the following:

Explain to the patient and her family that the nodules, although small, MAY indicated an underlying malignancy. However, given the patient’s age, and general good quality of life, the risk of doing a biopsy (which would likely have to be performed via an open thoracoscopic procedure) may actually be greater than the chance that the nodules are cancerous. She may likely decide for a more conservative approach where a CT scan is repeated in 6 to 12 months. She may decide, hell, I don’t want to go through all that! Even if it is cancer, she might not even decide to do anything aggressive about it!

Choice B is what we do in America:

Send the patient to a CT surgeon. He decides that before he will do a procedure she has to be medically cleared. She gets a cadiac echo by a cardiogist. It shows Aortic Stenosis and a wall motion abnormality. She gets sent to the interventionalist who does a cardiac cath. He finds some coronary blockages and stents them (even though she never had chest pain) but has to use bare metal ones (as apposed to drug eluting stents that require the patient to be on plavix) because otherwise, no CT surgery can occur for a year. He also attempts to open up the aoritc valve percutanesously. One week later, she gets a repeat echo that shows no improvement in her valve function. The next day she gets chest pain and comes back to the ER having acute ischaemia on the EKG. She gets another cath and this time they find the two bare metal stents are almost completely occluded. Now she gets rushed to the OR for a open CABG and a valve replacement. She gets runs of Vtach and gets a pacemaker. She finally gets sent to the nursing home for rehab but is not doing very well.

And still we don’t know what the hell those lesions in the lung are since she never was able to get the surgery.


About ER Jedi

I’m a resident doctor in Emergency Medicine and I’ve learned during the past few years that 1) I’ve had some pretty amazing experiences 2) I have a very bad short-term memory. So this blog is just a place for me to write about some of these experiences, from the ER, medical school, the wards and life in general. At least that way I’ll have some idea as to where I’ve been all this time. A scrap-book of sorts, a place to vent, organize some clinical tools and post a few good songs I’ve heard along the way.

Posted on May 18, 2011, in Health Care. Bookmark the permalink. 1 Comment.

  1. I searched for didactics and I found your blog. I really like it. Keep going – well done!

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