“Look at every path closely and deliberately, then ask ourselves this crucial question: Does this path have a heart? If it does, then the path is good. If it doesn't, it is of no use.” ~Carlos Castaneda

Wednesday, January 16, 2008

When in doubt, examine the patient ..

“Thinking is easy, acting is difficult, and to put one's thoughts into action is the most difficult thing in the world.”
~Johann Wolfgang von Goethe

As orthopaedic surgeons, we are not known for examining patients. A common orthopaedic joke is "the patient looked good from the door." Another common joke is the orthopaedic triple point, located in the center of the thorax at about the xyphoid, where you can listen to the heart, both lungs, and the abdomen. We all laugh and joke about it. The truth is we do examine our patients. We are more focused on our organ system, the musculoskeletal system, and that is considered less important than the heart, lung, and abdomen examination. When push comes to shove, most of us can examine the heart, lungs, and abdomen better than many physicians can examine the musculoskeletal system.

(Here is a case. Not picking on any service)

Several days ago, we were called to examine a child for possible compartment syndrome, an orthopaedic emergency. It was a child that had a boil on his knee, it burst, and now he has cellulitis with leg swelling. Because the leg was swollen, or as my patients like to say "swolt", we were consulted for compartment syndrome. So, I go up with one of my residents, and we examine the patient. When we get to the room, the patient is lying in his crib eating a cracker and smiling. The leg was swollen, but the patient was comfortable. Pain out of proportion to the injury is one of the hallmark signs. But, we understand, they probably didn't know the signs. We fill out a consult note, speak to the covering resident, and advise on getting an MRI to evaluate for osteomyelitis if doesn't improve.

Next day, my team visits the patient. He was on Vancomycin for a skin culture of MRSA. The leg was significantly better, and we moved along. Later in the day, my residents get a frantic call from the patient's resident. We were informed that we need to see the patient right away because they had necrotizing fasciitis. ?????????? Ok, sometimes I am slow, but usually necrotizing fasciitis is caused by Strep. and tends to progress very rapidly. This child got significantly better with only antibiotics and cultured Staph. We again see the patient. The patient is still getting better. The calls continue. The patients attending then calls my partner to ask why isn't this necrotizing fasciitis being treated. We again look at the patient. Patient is stable. So, were did this confusion come from? Our friendly radiologist mentioned a differential of cellulitis vs necrotizing fasciitis. It is not their fault, they haven't seen the patient. They are just reading in isolation. The patients physicians were asking us to treat this reading.

So, how do we rectify this situation? When in doubt, you should examine the patient.

“All truths are easy to understand once they are discovered; the point is to discover them.”
~Galileo Galilei


Midwife with a Knife said...

I always struggle with figuring out how to explain this politely. I mean, really, you can't rule out nec fasc on a plain film, and I'd bet the radiology report says something like, "likely cellulitis, can not rule out necrotizing fasciitis due to the presence of blah blah blah". Any way I can come up with will come across like, "hey, you idiot, learn how to read a radiology report, they always sound like that, and did you look at the patient?"

Bongi said...

this sort of thing happens quite a bit here. frustrating. i've even gotten to the point where i finally tell the internal guy "i'm not going to operate. if you want to, be my guest"

another joke about orthos here...an orthopod doesn't just treat the fracture. he treats the entire bone.

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