Appendicitis, An Old Nemesis

Calgary seems to be having some incredibly “bad luck” with mortalities related to acute appendicitis. If our mortality rate is elevated (and I say IF), one wonders about our morbidity rate. Is it possible that in today’s’ world of new technologies, incredible surgical skills, and powerful antibiotics, we as physicians, have lost our diagnostic skills and respect for that old, but still quite formidable disease, appendicitis. Before the use of abdominal ultrasound, CT scans of the abdomen and other helpful diagnostic modalities, several golden rules existed (at least as taught to me during my training and subsequently):
1) The surgeon is appropriately cautious if he/she removes an occasional “normal” appendix to prevent the morbidity/mortality that can occur from missing, or delaying intervention, in a patient with the presumptive diagnosis of acute appendicitis.
2) The white blood count can not be used to either include or exclude an acute appendicitis.
3) The physician should, if appendicitis is a possibility, refrain from using antibiotics since they may give both the patient and the physician a false sense of security.
4) As a general rule, a patient is “safe” in the first 24 hours from the onset of symptoms, BUT, thereafter there is an increase in morbidity and mortality as time elapses before surgery.
Four years ago at an educational conference on emergency medicine, statistics revealed that the two conditions most commonly resulting in legal action were appendicitis and ectopic pregnancy. That statistic is likely still true today. It is well recognized that the diagnosis of appendicitis is extremely difficult in the very young (under two years of age) and the very old, but Calgary’s mortalities have occurred in the usual age group for appendicitis. The Calgary Herald reports that the Calgary Health Authority has pledged several changes to its approach to appendicitis, including enhanced communication with patients and families who are involved with “serious adverse events” in Calgary hospitals. I certainly hope the changes are substantive, and constitute more than a public relations exercise.

Peemptive Strikes, Ramblings of a Gardener.

This world is getting far to complex for me. As an example, there has been much discussion about the legitimacy of the term “preemptive” as in “preemptive war”. Wikipedia defines preemptive war as an attempt to repell or defeat a perceived or imminent offensive or invasion, or to gain a strategic advantage in an impending war.
As a physician I personally have knowledge of many surgeons who preemptively attack cancer with fairly aggressive and even life threatening surgery. Most of their patients have considered them some kind of hero. Wikipedia goes on to state that preemptive war should not be confused with the term “preventive” war since the latter is generally considered to violate international law, whereas preemptive wars are more often argued to be justifiable.
Now I’m really confused! Preventive medicine is deemed to be the salvation of our healthcare system in Canada, and any physician not swearing allegiance to preventive medicine simply is a dinosaur and is costing our system zillions of dollars. Why is it O.K., desirable, and even mandatory, to practice preventive and preemptive medicine, and not preventive and preemptive war? Which brings me to how I began pondering these imponderables.
Yesterday I practiced preventive something or other when I applied a generous portion of “OFF” insect spray to my person before I ventured to do my planting and gardening. For a period of a few hours this seemed effective, but as the day wore on it became obvious that my “preventive” techniques were failing. Being an environmentalist, I hesitated to once more contaminate myself and the environment with this repellent. Instead I attempted to negotiate with the hoards of mosquitoes that seemed determined to invade my space, and I believe, have significant harmful intentions to my person. At first I spoke kindly and reassuringly, on the chance they had an abusive upbringing. Then I became more impassioned since they may simply be misinformed. Finally, I waved my arms in a sinister way, occasionally making impassioned pleas and voicing convincing arguments and warnings. My efforts seemed in vane. It definitely seemed the intent, and indeed, the nature of those creatures, to feast on my body. At last I resorted to a preemptive attack, and although my swatting destroyed many, soon my exposed skin was crimson from self inflicted slapping. It seemed the only solution was to retreat from my yard and garden and become a prisoner in my own home.
Tonight I will contemplate both a preemptive and preventive strike for tomorrow. To recapture the use and freedom that is the right of every earthly creature, I will spray my grass and bushes with a dilute solution of malathion (now I’m going to be in trouble with the environmentalists for sure). The other question is what I could do with my neighbors’ pond that he refuses to drain or treat (my intelligence sources inform me that the pond is the epicenter of the threat). Perhaps a preemptive/preventive strike in the middle of the night? No, no! Not the neighbor; the pond!

Investigate While We Wait

Today I recalled an episode of a T.V. program called “Yes Minister” (comedy) in which a hospital in Great Britain had won numerous awards for its efficiency, but actually didn’t attend to any patients! The thought occurred to me while waiting for my wife, that it would be interesting to track the number of administrative and other personnel in the regional health authorities employ that are not patient service providers. I know that there was a time in the 1990’s when there was significant downsizing in this area. I also know that there was a rebound rehiring, shortly thereafter, as the Calgary and other Regional Health Authorities realized that they would need help in managing a system where there was increasing demand and decreasing resources (facilities and caregivers), available for direct patient care. But exactly what has been, and what is, happening up there at the top?
As I dropped my wife off at the Okotoks Urgent Care Center Laboratory, I observed a waiting room full of people, and people standing in the hall, all waiting for blood tests of some description. I noted two people in the urgent care area (a truly large waiting area about three times the size of the lab. area). On arriving that morning, there was nowhere to park in the patient designated parking area (with many parked on the street), but quite a few parking spaces in the “staff” designated parking area. Since I had to wait an hour and twenty minutes for my wife, I wiled away my time counting parking spaces; approximately 34 (including handicapped parking) for patients, and 64 designated for staff.
Later in the day as I planted my bedding out plants (a great time to do some idle thinking), the thought occurred to me that there are likely more people available for hire in the areas of “health management”, health education, public relations, and many other areas, than there are people available for direct patient care (doctors, nurses, technicians, etc). I wonder if there is an increasing part of our health care budget going to “manage” the areas of shortcomings. Some of this is, of course, constructive and necessary, but how far can we stretch shortcomings with better management? Has the department of public relations expanded in an effort to convince the public that there is not a problem with our health care system, there is only the PERCEPTION that there is a health care problem? And who the heck was involved in planning the Okotoks Urgent Care Center, and in particular, the parking areas? Was a doctor involved at all? Any community family physician could have told them they would need more space and staff for the laboratory area!
Why all the landscaping and public appeal at the patient’s entrance and none at the staff entrance? Could they not have taken some of the designated esthetics for the patient entrance and provided more patient parking? And where are all the people that belong to all the cars in the “staff” parking area? Behind closed doors, I guess, and certainly not working in the laboratory. And if you are thinking that this blog entry is quite disjointed and rambling, who says that random thoughts while gardening or waiting one hour and twenty minutes for a blood test need to be organized and pithy? Hey, maybe that’s the amswer? If everyone dissected our health care system, or better still, came up with solutions, while they waste a good part of their lives WAITING, maybe we wouldn’t be at this stalemate. Let’s face it; it would represent millions of hours of contributed thought.