What Was He Thinking?
Today I am mad! This morning when I woke up at 5:30 A.M. I was mad, and I’m still mad! Perhaps I shouldn’t write about isolated medical events, and perhaps I shouldn’t write a blog when I’m angry, but it is my blog and the title to it is “What’s wrong with our Health Care” so here goes.
Last night when my wife was talking to her friend on the phone, her friend mentioned that her husband had a strange spell six weeks ago. Apparently he suddenly fell at home for no reason, breaking a coffee table. Picking himself off the floor he noted that he was wobbly and unsteady but decided to go to the closest town for some supplies. The nearest town did not have what he wanted so he ventured to the next town, a twenty minute drive away. He noted that when he was driving, the car kept drifting to the left, never to the right. A short while later while waiting in line at a store, he once again found himself on the floor. He drove home and called his wife. His wife stated his speech was slightly slurred (he had consumed no alcohol). When his wife got home she thought there was some slight irregularity to one side of his face. They went to an urgent care clinic.
I know this man as a neighbor, not as his physician. He is 61 years old, and I would estimate his BMI to be in excess of 30, his waist to be in excess of 40 inches and he tells me that when he was seen at the urgent clinic his Blood Pressure was greater than 190/100. He has been on blood pressure medication for ten years and apparently was tried on cholesterol lowering medication but got leg cramps, so he has been on nothing for cholesterol. He is a 40 pack years smoker although he stopped smoking three years ago. His father had a myocardial infarction followed a year later by a stroke that ended his life. This man has at least six risk factors for vascular disease.
At the conclusion of their visit to the urgent care clinic a chest X-ray had been done, blood drawn, and an EKG was done. I would hope with the blood work a tropinin was done to help rule out heart damage. Apparently, blood gases showed a “low oxygen level” so pulmonary function tests were ordered for three months down the road. I’m not sure what the chest x-ray was for. If they were thinking about a pulmonary embolus a chest X-ray was not likely to help. He would have needed at least a lung scan. He reported no sweating, fever, chills etc. so pneumonia was highly unlikely. His BP was elevated on arrival and he had no abdominal pain so one can exclude an Abdominal Aneurysm leak. They excluded a myocardial infarct---so what is left. Some lateralization in the history and the history itself, is strongly suggestive evidence of a neurological event, and the most likely event would be a TIA (transient ischemic attack). Other possibilities would have to include a sub-arachnoid bleed or brain tumor but the entire episode lasted about one to two hours and then was gone, with no remnant physical findings. At no time did he have a headache so these latter two possible diagnoses would be highly unlikely.
With all this information the patient and his wife were told the physician did not know what had happened. The patient remembers someone saying at some time something about a TIA. The patient was sent home on aspirin (so obviously TIA crossed someone’s mind) and advised re follow up for his blood pressure and that the target BP was 140/90. No other investigation or intervention had been planned other than the respiratory function tests booked for three months later as I previously mentioned.
What was his doctor thinking? Or was he thinking at all? The morbidity and mortality in the first year following a TIA without aggressive intervention is horrendous. When all is considered the working diagnosis in this case is undoubtedly a TIA. This indicates unstable vascular disease and mandates aggressive treatment. At the time he was seen a CT scan of his head should have been considered and at the very least an echocardiogram and bilateral carotid dopplers (ultrasound examination of his carotid arteries in his neck) should have been arranged. His target blood pressure should be 130/80 or less and his LDL cholesterol should be in the basement (less than 2.0). He should be on a large dose of an ACE inhibitor (he is on 5mg. of vasotec---very small dose--- and his blood pressure is 145/90 at home, and he is on no cholesterol lowering drug (it is six weeks after the event). A referral to the Stroke Prevention Clinic should have been put in place.
Again, what was his doctor thinking! Has our preoccupation with cost effectiveness so clouded our judgment that we are putting patient’s lives at risk? Have we forgotten that we as family physicians must first and foremost be advocates for our patients? Perhaps he simply is unaware of the huge financial burden of strokes on society. Perhaps he has not seen enough post-stroke people killed, in wheel chairs, or converted to a “vegetable” state to understand how important it is to grab the opportunity that a TIA offers us as physicians, to make a real difference in a patient’s life-----for better or worse. This was a rare window of opportunity to initiate life saving measures. If something happens to this patient before proper care is initiated and the case appears in a court of law, I will be an expert witness for the plaintiff, not the defense (my usual role) although I truly hope nothing untoward happens (I have informed him of what needs to be done). Our role as physicians is to diagnose and treat appropriately those conditions that can kill and maim our patients. As I’ve said: “What was he thinking”?
Last night when my wife was talking to her friend on the phone, her friend mentioned that her husband had a strange spell six weeks ago. Apparently he suddenly fell at home for no reason, breaking a coffee table. Picking himself off the floor he noted that he was wobbly and unsteady but decided to go to the closest town for some supplies. The nearest town did not have what he wanted so he ventured to the next town, a twenty minute drive away. He noted that when he was driving, the car kept drifting to the left, never to the right. A short while later while waiting in line at a store, he once again found himself on the floor. He drove home and called his wife. His wife stated his speech was slightly slurred (he had consumed no alcohol). When his wife got home she thought there was some slight irregularity to one side of his face. They went to an urgent care clinic.
I know this man as a neighbor, not as his physician. He is 61 years old, and I would estimate his BMI to be in excess of 30, his waist to be in excess of 40 inches and he tells me that when he was seen at the urgent clinic his Blood Pressure was greater than 190/100. He has been on blood pressure medication for ten years and apparently was tried on cholesterol lowering medication but got leg cramps, so he has been on nothing for cholesterol. He is a 40 pack years smoker although he stopped smoking three years ago. His father had a myocardial infarction followed a year later by a stroke that ended his life. This man has at least six risk factors for vascular disease.
At the conclusion of their visit to the urgent care clinic a chest X-ray had been done, blood drawn, and an EKG was done. I would hope with the blood work a tropinin was done to help rule out heart damage. Apparently, blood gases showed a “low oxygen level” so pulmonary function tests were ordered for three months down the road. I’m not sure what the chest x-ray was for. If they were thinking about a pulmonary embolus a chest X-ray was not likely to help. He would have needed at least a lung scan. He reported no sweating, fever, chills etc. so pneumonia was highly unlikely. His BP was elevated on arrival and he had no abdominal pain so one can exclude an Abdominal Aneurysm leak. They excluded a myocardial infarct---so what is left. Some lateralization in the history and the history itself, is strongly suggestive evidence of a neurological event, and the most likely event would be a TIA (transient ischemic attack). Other possibilities would have to include a sub-arachnoid bleed or brain tumor but the entire episode lasted about one to two hours and then was gone, with no remnant physical findings. At no time did he have a headache so these latter two possible diagnoses would be highly unlikely.
With all this information the patient and his wife were told the physician did not know what had happened. The patient remembers someone saying at some time something about a TIA. The patient was sent home on aspirin (so obviously TIA crossed someone’s mind) and advised re follow up for his blood pressure and that the target BP was 140/90. No other investigation or intervention had been planned other than the respiratory function tests booked for three months later as I previously mentioned.
What was his doctor thinking? Or was he thinking at all? The morbidity and mortality in the first year following a TIA without aggressive intervention is horrendous. When all is considered the working diagnosis in this case is undoubtedly a TIA. This indicates unstable vascular disease and mandates aggressive treatment. At the time he was seen a CT scan of his head should have been considered and at the very least an echocardiogram and bilateral carotid dopplers (ultrasound examination of his carotid arteries in his neck) should have been arranged. His target blood pressure should be 130/80 or less and his LDL cholesterol should be in the basement (less than 2.0). He should be on a large dose of an ACE inhibitor (he is on 5mg. of vasotec---very small dose--- and his blood pressure is 145/90 at home, and he is on no cholesterol lowering drug (it is six weeks after the event). A referral to the Stroke Prevention Clinic should have been put in place.
Again, what was his doctor thinking! Has our preoccupation with cost effectiveness so clouded our judgment that we are putting patient’s lives at risk? Have we forgotten that we as family physicians must first and foremost be advocates for our patients? Perhaps he simply is unaware of the huge financial burden of strokes on society. Perhaps he has not seen enough post-stroke people killed, in wheel chairs, or converted to a “vegetable” state to understand how important it is to grab the opportunity that a TIA offers us as physicians, to make a real difference in a patient’s life-----for better or worse. This was a rare window of opportunity to initiate life saving measures. If something happens to this patient before proper care is initiated and the case appears in a court of law, I will be an expert witness for the plaintiff, not the defense (my usual role) although I truly hope nothing untoward happens (I have informed him of what needs to be done). Our role as physicians is to diagnose and treat appropriately those conditions that can kill and maim our patients. As I’ve said: “What was he thinking”?
posted by Al | 9:20 PM
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