What's Wrong with Healthcare?

Thinking inside and outside of the healthcare box. After 41 years of family practice, what's happened to Canada's healthcare system?

Thursday, September 13, 2007

MDAnderson Medical Center, Houston, Texas

Chapter 4, Some Surprising Information

Technology can be a wonderful thing. Within 36 hours of requesting patient referral information from the MDAnderson Cancer Center, I received the necessary forms via E-Mail. The forms were completed and appropriate information was provided and returned. Surprisingly, an appointment was not obtained for three weeks, and this was with a gastroenterologist specializing in carcinoid malignancies. Of interest was a request for a line of credit to be established for $50, 000.
At first I was taken aback, and then I remembered that 18 years ago when I was having a dispute with our Canadian tax department, the firm I wanted to represent me requested a $50,000 deposit to take the case on. We as Canadian physicians in the Canadian socialized system have totally lost track of the relative value of our services and simply think “small”. The thought also crossed my mind several times since then as to whether Canadians can take out health insurance to cover them for American health care (seems to me there is a business opportunity there!!).
In any event the line of credit was arranged, and Mr. L.D. was seen at the MDAnderson Cancer Center, Houston Texas. In three days he had been seen by the medical oncologist, the chest surgeon oncologist, the abdominal surgeon oncologist, had all the special scans done, blood work done, (that, in Canada, take two weeks to get the needed blood test results, and as indicated previously, months for the opinions and diagnostic imaging) , and was given their considered opinion. That opinion was as follows:
1) Surgery was the best approach to his problems. Since the cancer was relatively slow growing and hormone producing, debulking was the approach of choice. Further it was proposed that the liver tumors (cancer), were to be approached first since they consisted of 90+% of his tumor load and the size of the liver growths interfered with his pulmonary function. Further, they suggested that he would have 50% more liver left after the surgery than he would need to survive the surgery (note that, here in Canada, he was told that he would not have enough liver left to survive the surgery). He was given a mortality rate of 1.5% with this surgery.
2) It was recommended that two to three months after the abdominal (liver) surgery he should have a lobectomy for removal of the lung cancer. Their pulmonary assessments suggested that he would have sufficient respiratory function after the lobectomy to tolerate the procedure and suggested a 1.3% mortality rate with this procedure.
3) If he survived these two procedures he was given a life expectancy of four to five years. Please note; here in Alberta a mortality rate of 5% was given with embolization alone which, at best would shrink one liver tumor. Here in Alberta he was given no chance of surviving the abdominal surgery, approximately six months to live, and offered palliative care only. At the MDAnderson Clinic, a combined mortality rate of 2.8% was given for REMOVAL of all three liver cancers and the primary lung cancer, and a four to five year life expectancy. Which would you choose? (A cure was not possible because Mr. LD had a small metastatic bone lesion in his left humerus).
4) He was told to go home, consider and discuss the options with his family and physicians, and let them know. The first surgery could be booked in a matter of weeks.
The patient, of course, opted for the program proposed. He flew to Houston, had his surgery and was discharged after six days in hospital. He remained in Houston following the surgery for ten more days, was treated as an out patient with I.V. antibiotics for a wound infection, and returned home feeling well except for post operative pain. It should be pointed out that the surgery (my impression from reading the three page operative report), was quite incredible. Using an intra-operative ultrasound, all three liver cancers were removed during a seven and one half hour operation. The approach used in the surgery had to be modified with access posteriorly because the cancer was partially surrounding the inferior vena cava (main vein returning blood to the heart from the lower part of the body), and much time was spent dissecting the tumor away from this major blood vessel. It was apparent to me had this surgery not been done, the cancer would have invaded/choked off this blood vessel eventually with dire results.
Within three weeks of the patient returning home, he developed incapacitating diarrhea with fever and decreased blood pressure. I sent him to Calgary’s “hospital of excellence” emergency department, informed them of my concern for a C. deficile infection since he had I.V. antibiotics three weeks prior, and requested a stool culture be done. I was informed that it was not necessary, Mr. LD was given two liters of intravenous fluids for dehydration, and sent home. I must say, this amazed me; a post operative cancer patient (impaired immunity), had I.V. antibiotics less than a month prior, symptomatically deteriorating from diarrhea, and a stool culture is NOT DONE. Needless to say, when the patient got home six hours later I arranged for a stool culture, the culture came back as food poisoning, and because of the fever and the circumstances (debilitation/cancer) he was treated with the appropriate antibiotic. He breezed through the remainder of his post-operative period.
Three months later he had his lobectomy to remove his primary lung cancer. He was discharged after five days in hospital, and remained in Houston for an additional ten days, and then returned home. His progress postoperatively here was uneventful.
Next, Chapter five, How is Mr. LD doing now?



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