Wednesday, January 4, 2012

How reliance on expensive and unnecessary tests can endanger our patients

I just completed two weeks as the inpatient attending on the medical wards. As the attending I supervise residents and care for 12-20 patients in the hospital. One patient exemplifies how over dependence on sophisticated imaging studies can endanger our patients. I admitted a patient with severe abdominal pain, and serum tests demonstrated an elevated amylase and lipase indicating pancreatitis (inflammation of the pancrease). An abdominal CT scan showed minimal swelling of the pancrease and a normal common duct (drains bile from the liver); however his gallbladder was filled with gallstones. Initially we treated him with intravenous fluids, held all food by mouth, and administered pain medications.

Over the first two days he improved; however, on the third day he developed fever to 103 degrees and his blood pressure dropped to 70. He became confused and complained of worse abdominal pain that had moved from the midabdomen to his right upper quadrant (near the liver). On abdominal exam he had severe tenderness in the area of the liver. His peripheral WBC increased from 8,000 to 24,000 (normal 4,000-10,000) indicating a new bacterial infection. His serum bicarbonate dropped from 25 to 19, and his serum lactate increased to 4.0 (indicated lactic acidosis a very dangerous condition). His liver function tests suggested early obstruction of the biliary duct draining bile from the liver.

All his clinical findings indicated that a stone in his gallbladder had blocked off bile drainage and that he now had what is called "cholangitis".  Gallbladder obstruction leads to inflammation of the walls and the high pressure in this small pouch causes bacteria to spill into the blood stream. My patient was in septic shock!

At 8AM I  called our interventional radiologist to emergently place a drain (tube) in his gallbladder to relieve this pressure build up, drain the pus, and stop bacteria from spilling into his blood stream.  Despite the classic signs of gallbladder infection and septic shock, the radiologist refused to place a drain without a repeat CT scan! But I insisted there was no need for another test, he needed the drain NOW. The diagnosis was clear, however he again refused. I transferred my patient to the ICU and arranged for a critical care nurse to accompany him to have his unnecessary CT scan. The test showed inflammation of the gallbladder and his drain was finally placed 12 hours later at 8PM. Pus gushed from the gallbladder and within 8 hours he no longer had fever, and his blood pressure returned to normal.

He had survived, but this inordinate delay for an unnecessary and expensive test could have proved fatal.  The radiologist understood imaging, but he had not examined the patient, and did not accept my clinical assessment. He only trusted his expensive test. As this case exemplifies, in this era of extreme specialization the lack of trust and teamwork can result in unnecessary tests and can endanger our patients.