Monday, January 28, 2008

When Medicine Gets in its Own Way

As of this morning, my mother's still in the hospital, still waiting for the barium to leave her system so she can have the CT scans she needs to diagnose what's wrong. I guess they'll keep trying every day, but in the meantime she has to stay there: and once she has a diagnosis, she'll have to stay long enough for them to treat it.

The irony here is pretty obvious: the test she had the day before she went into the hospital, and which had nothing to do with the apparent cause of her hospitalization, is keeping her from being treated promptly. The efforts of one set of providers to care for her have stymied another set of providers, who also want to care for her.

I wonder how often this happens, how often medicine trips over its own feet, so to speak. We all know about the most horrible cases: thalidomide given for morning sickness causing profound birth defects, for instance. But I wonder how often there are quieter, more personal stories like my mother's, seemingly insignificant ones that don't make the news. Of course, if Mom's condition is really nothing worse than pneumonia -- as serious as that is -- the delay will be nothing but an annoyance. But her doctors are trying to rule out a cancer recurrence. In someone my mother's age, cancer spreads slowly, but in a younger person, could an annoying delay because of a previous test make a significant difference in treatment outcomes?

When I was talking to my father the other day, he mentioned the recent news about possible links between CT scans and cancer:
A new study in the journal Radiology points out that the radiation from a full-body CT scan may actually raise the risk of cancer as it's trying to detect it. They looked at people who were exposed to radiation from atomic bombs in Japan during World War II in amounts equivalent to a full-body CT scan.

They estimate that one full-body CT scan at the age of 45 increases the risk of cancer by one in 1200. Not a huge risk. But if that same person gets the same scan every year until age 75, the risk of cancer goes up to one in 50. That's a big risk.
Mom was diagnosed with breast cancer in 1987. In 1992, she had a stroke. In 2003, she was successfully treated for Stage-1 lung cancer. Last year, she had surgery to repair an abdominal aneursym, following a series of scans to track the increasing size of that aneurysm.

I'm not sure how many CT scans she's had, but she's had a lot. And they've done what they were supposed to: she's survived cancer twice, and the AAA was repaired before anything awful happened. Her doctors caught the lung cancer at Stage 1 -- when it was still treatable entirely with surgery -- specifically because they'd been scanning every cell of her body every year since her breast cancer. (Breast cancer as blessing: who knew?) If she hadn't gone in for a routine scan, we wouldn't have known about the lung cancer until it was too late.

She's benefitted enormously from medical technology, but now I find myself wondering if there are ways in which she's been harmed, too. And in the meantime, we're waiting for that stubborn barium to go away, so she can finally have, yet again, another CT scan.


  1. While shadowing in the ER over my Christmas break, I saw an instance that could be described as this.

    A young man came into the ER complaining of abdominal pain, and the ER doc was fairly certain he had acute apendicitis. So he sent him up to the CT suite to get an abdominal CT.

    A few minutes later, they brought him tearing back into the ER in a full-fledged anaphalactic reaction that he'd just had to the contrast dye.

    So the ER doc had to pump him full of adrenaline and benadryl and wait for his breathing to come back to normal, before they could send him up to the OR to get his appendix out.

  2. Beach Bum -- Yep, good example! My primary-care doc gets annoyed at giving appy patients CTs in the first place: her attitude is that if somebody has a fever, nausea/vomiting, and severe lower-right abd rebound pain with guarding, the docs should just go ahead and do the appendectomy.

    A long time ago, I read that medical students are taught that if one of three appendixes they remove isn't healthy, they aren't operating often enough. Is that still the prevailing standard?

    Oh: my mother, by the way, also survived a ruptured appendix when she was five years old, in 1930.

  3. Susan, How frustrating for everyone. I hope that this test gets done soon or they figure out another way to find out what they need to know. Prayers are still ascending.

    Peace! & Hope!

  4. From what I understand (mostly from reading surgeon's blogs), the abdo CT is now standard of care in suspected appendicitis. For the most part now, they won't cut unless the symptoms are totally classic, or the CT has been done. I think the number is now closer to one in ten or smaller.

  5. I just came out of my surgery rotation for 3rd year of med school, and was taught that a 20% rate of non-appendicitis "appys" is the goal. Any higher and you're operating too much, any less and you're missing an appy.

    The problem is defensive medicine, and surgeons want to be able to defend themselves if they are sued.

    An option outside of CT to diagnose acute appendicitis is ultrasound. It's non-invasive and has no radiation. The drawback is that some centers don't staff US all night/weekend in the ER, and it's difficult to use in an obese patient (US waves "don't like" fat, it clouds the view).

    More and more we're being taught to ration CTs and XRays because for every dose of radiation you give a patient, you increase their risk of cancer. Multiply that by a thousand cases, and you've just given someone cancer. It's a scary thought. My hope is that MRI becomes a cheaper modality, as its resolution is higher than lose-dose CT scan, and doesn't give any radiation.

    One can always hope.


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