ct scan Archives - Where Is The Outrage?

End of life discussions are hard enough

I posted this several years ago. I think that it is worth posting again.(Besides, I don’t know what to make of Rick Santorum.)

When Sarah Palin wrote, “the America that I know and love is not one in which my parents or my baby with Down Syndrome will have to stand in front of Obama’s ‘death penalty’ so his bureaucrats can decide, based on a subjective of judgment of their ‘level of productivity in society,’ whether they are worthy of healthcare. Such a system is downright evil,” I got physically nauseated. The only reason that former Governor Palin said this was to derail healthcare reform and to try to elevate her own status in the conservative movement. The statement had no basis in reality. My nausea stems not from a lie, but from this person unknowingly making my job harder. Speaking with real patients about real end-of-life issues is incredibly difficult.

The following is an example of an end of life discussion. It has been fictionalized to protect patient’s privacy. A 80-year-old man presented after a fall at home. The patient had been in declining health for some time. He has an abnormal heart rhythm and congestive heart failure. He is on blood thinners because he is at increased risk of developing clots in his heart. The patient is awake and alert on arrival. A CT scan is obtained of his brain which reveals blood between the brain and the skull — subdural hematoma. The patient is admitted to the intensive care unit for observation. Medications are given to reverse his blood thinners. The patient does well overnight in a repeat CT scan (standard practice) performed to see if anything new has shown up. The patient has a new contusion (bruise) on his temporal and frontal lobes.

The patient, who was lucid throughout the night, is now somewhat confused. He is having some problems finding his words. His son, who is an orthopedic surgeon, had been with the patient through the night. The son is now extremely concerned. He wants to know what happened. I review the CTs with him and point out that the contusion is in the area of the speech center of the brain. This should explain his difficulty finding words.The son wanted a repeat CT scan, in spite of the fact that the second scan was only completed four hours ago. I asked whether, if we find a surgical lesion (something that can be operated on), he would like me to call a neurosurgeon. I asked if he wanted his father to undergo brain surgery if it is necessary.

I think this question is more than reasonable. Thankfully, the son never had to make that decision. The repeat CT scan was the same as the second scan. Neurology was consulted. Over the next several days, the patient slowly improved and was able to be discharged to a rehabilitation center.

You know our society is in trouble when a physician has not thought about end-of-life issues concerning his 80-year-old father who has a bad heart. From a medical standpoint, I just want to do what is right for the patient, which is to follow that patient’s wishes. Yet so very few families have talked about end-of-life issues. You don’t want to be in the position of the son where you’re having to make a decision while looking at a CT scan in the middle of an ICU. Instead, you would like to be able make decisions in the privacy of your physician’s office.

I deplore any politician that makes this situation harder. Emotions are overwhelming when families are faced with these types of decisions. Exploiting end-of-life issues for political gain should get those politicians a special place in Dante’s Inferno.

By ecthompsonmd|2012-02-08T05:57:03-04:00February 8th, 2012|Congress, Healthcare|Comments Off

Healthcare Week: End-of-life care? (Update)

Sometimes, when I see what the mainstream media is talking about, I get physically nauseated. Probably 80% of the time, we are focused on nothing. Whether it is Britney Spears or Reverend Wright or, currently, a pay freeze for all federal employees, we continue to miss the big picture. Freezing pay for federal employees will not solve the deficit. It won’t even come close. It is an excellent example of a stupid policy.

Back to healthcare. About 18 months ago, I sat down to write a book on healthcare. I thought I knew a little bit about healthcare. I’ve been a trauma surgeon for over 15 years. My father, whom I used to help in his office, was a family practitioner. So I’ve been around healthcare for more than 30 years. I have seen something as simple as an examination table cost more than $1000. In the course of my health care research, though, I became overwhelmed by the amount of data and the simple size of the task. Healthcare is a vast monstrosity. It is extremely difficult to get your arms around the whole problem. Therefore, it makes sense to me that we need to examine this problem in small pieces. Let’s look at the intensive care unit. In the intensive care unit, physicians practice some of the most advanced medicine that can be found anywhere in the world. Although I do not like to use case reports (anecdotes) as inspiration for action, they can illustrate a larger point.

Case 1: a 90-year-old gentleman was driving a golf cart on the road when he swerved to miss a car. The golf cart rolled down an embankment and the gentleman was thrown from a golf cart and hit his head on a rock. A witness saw this crash and called for an ambulance. The patient was awake and alert when the ambulance arrived and he was taken to the trauma hospital. The patient arrived at the trauma center complaining of a headache. The CT scan of his head revealed a small subdural hematoma (a collection of blood between the skull and the brain) near the temporal lobe. There was a small contusion (bruise) of the temporal lobe. The rest of the CT scan was perfectly normal for a 90-year-old gentleman. (This subdural hematoma does not require neurosurgical intervention.) At this time, the patient began having some language difficulties, was becoming a little confused and was admitted to the intensive care unit. Interestingly, the patient’s son was a pathologist. He was informed of his father’s condition. The next morning, per protocol, the patient had a repeat CT scan of his head. It was completely unchanged. Approximately four hours later, the patient’s mental status began to deteriorate. He was now having severe difficulty finding the correct words to express himself and was becoming agitated. At this time, the patient’s son came by for visitation. The son, extremely alarmed at the deterioration of his father, demanded that something be done. He informed the critical care physician that this patient lived independently was highly functional. The pathologist wanted a repeat CT scan. The critical care physician asked a few questions – what if the CT scan was worse? Did he want his father to undergo a neurosurgical procedure/surgery if necessary? How aggressive did he think they should be with a 90-year-old gentleman who was previously healthy? The pathologist, a physician, was unable to answer any of these questions. (Please remember that none of the patients presented here are real, but are presented to illustrate a point.)

What do you think should be done? Should we get a repeat CT scan emergently? Should we just keep the patient in the ICU (at a cost of $1000 – $1500/day) and watch him closely with continued IV fluids and supportive care? Should we transfer this patient out of the ICU to a regular room and institute “comfort measures?” (Case 2 tomorrow.)

Update: To continue with this case, the patient did undergo a repeat CT scan at the request of the family. The repeat CT scan was unchanged. Neurology was consulted. They came by and explained to the family that the patient’s symptoms were due to the bruise in his temporal lobe. It was unclear if these symptoms would resolve themselves or not. Over the next 24 hours, the patient’s symptoms improved and the patient was transferred out of the intensive care unit to a regular room. Over the next 48 hours, the patient continued to improve and was back to baseline. (He was walking, talking and eating without difficulty.)

I posted this case not as some sort of “miracle,” but as an exercise in thinking about end-of-life issues. How can a physician whose father is 90 years old not have some sort of plan with regard to end-of-life issues? If a physician cannot have a plan then what chance do the rest of us have?

Finally, I would like to address a sentiment that I noticed over at the Daily Kos (I posted this case there also) and also here on my blog, “hurry up and die.” If you read this case and you feel that the medical team was trying to push this 90-year-old man into the grave, you’re sadly mistaken. Instead, all medical teams should be weighing the risk versus the benefit of all therapies. A craniotomy in a 90-year-old has a survival rate of less than 5%. On the other hand, watching, waiting and evaluating turned out to be the right thing to do. By making sure that the patient’s blood pressure was adequate, giving the patient an adequate supply of oxygen and providing appropriate nutrition, the medical team put this patient in a position in which he could heal himself. What was the risk of a repeat CT scan? Not much. That’s why the medical team thought it was okay to order repeat scan. Yes, there was added expense, but it also put the family’s mind at ease. This is also important.

By ecthompsonmd|2010-11-30T21:32:52-04:00November 30th, 2010|Healthcare|Comments Off

The Real Question is Cost

CT scan About 10 years ago, I was working as an emergency room doctor at a small community hospital. A 25 year-old gentleman came in with a bump on his head. It seems that while he was working, he turned around and hit his head on a metal pole. The gentleman had a small goose egg in the middle of his forehead, otherwise known as a hematoma. I asked all of the important questions and the patient said “no” to all of them. I gave him all of the warnings of what to look for that would be cause for concern. Then, I wrote a prescription for pain and discharged him.

If you could have witnessed the scene that man put on in the emergency room. He complained that I didn’t know anything, that I was a quack. He said he was seriously injured and that I needed to do some tests.

The standard of care is to get a CT scan on all patients who experience a loss of consciousness. Most physicians do not want the scene that I described above. It is faster for them to order the CT scan, get the normal results back, then talk to the patient armed with a negative CT scan. Most patients come to the hospital with expectation; They want the physician’s time and they want tests. This is reality.

Also, the fear of lawsuits is real. A physician exam is subjective. A CT scan is objective (for the most part). It is something that you can show the jury that will save a physician’s butt.

There is a new AP article that suggests that insurance companies are taking a closer look at what scans need to be ordered. Look for the medical community to push back big time. The medical community may join with patient advocacy groups to take on the insurance companies. Physicians must be able examine their patients and discuss a course of action that will lead to a diagnosis. Insurance companies should not be allowed to insert themselves between the physicians and the patients (any more than they already are).

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From AP:

Insurance companies are taking a harder look at advanced medical scans like CT scans, citing spiraling costs and safety concerns. And some doctors agree there’s emerging evidence that these scans are being over-prescribed.

“Costs are soaring in this area, quality concerns are mounting and safety concerns are mounting,” said Karen Ignagni, chief executive officer of the trade group America’s Health Insurance Plan.

Health insurers are requiring more preauthorizations before patients can receive these scans, and setting other restrictions including mandating that the imaging equipment and medical staff operating it be credentialed in advance. (more…)

By ecthompsonmd|2008-03-23T18:46:37-04:00March 23rd, 2008|Medical Ethics/Issues|Comments Off