Wednesday, April 25, 2007

Who can blame him?

From a friend, who was looking for a referral to a new surgeon:

I cut myself on a shattering glass jar with high force, so that the glass penetrated about 3 centimeters into my right hand, on the side, below the little finger. I went to my college's medical center, where the nurses stitched up the wound but did not clean it past the outside or check for foreign bodies.

One week later I went to get the stitches out, and complained that part of my little finger was numb, and that certain motions of my hand and arm caused sharp pain near the site of the wound and along the whole length of my arm.

The nurse on duty suggested that I may have nerve damage, and, due to my concern over the possibility of glass shards in my hand, the nurse on duty ordered a CT scan of my hand. The radiologist report indicates that there are several 1-mm fragments of glass on the dorsal side of the metacarpal-phalangeal joint of my little finger, as well as one smaller 0.8mm shard on the other side. Based on this duty, the nurse referred me to a plastic surgeon, Dr. X.

I went for a consultation with Dr. X at his office at X Hospital. He said that I likely had nerve damage, and that he would do the following:

A. Perform exploratory surgery
B. Repair the nerve with microsurgery
C. "Dig around" to see if he could find the glass, which he assured me "was like looking for a needle in a haystack".

I told him that a CT scan existed showing the location of the glass.

He asked me to go to radiology and pick it up. When I returned with the compact disc holding the scan, he asked his secretary to bring it up. The two of them looked at the computer in the office for about three minutes, then he informed me that he could not see any glass, but that he would have a consultation with the radiologist to verify his conclusion, and that, in any event, "foreign bodies of any significance will make themselves known." He then muttered that he was "supposed to be out of here by 1:00 PM today," and the appointment was over.

Surgery is scheduled for May 2.

After this consultation, I went down to radiology and got another copy of the CT scan CD. I returned to work, placed the CD into my computer, and within about five minutes was looking at a detailed diagram, annotated with arrows, showing the exact location of the glass shards in my hand. I am perplexed as to how Dr. X could possibly conclude that there was likely not glass in my hand, and can only conclude that he was lying to me in order to get out of the office by 1:00 PM.

This has made me very reluctant to have him operate on me.

14 comments:

Ted said...

This is an interesting post. First becuase the surgeon asked you to go get the CT scan pick it up and bring it back. If the surgeon does regular business with the hospital why does't he have access to the images electronically already. The CT is already DICOM standard if they can kick out CD's.

Second because you are having doubts about whether or not to use him as a surgeon. Don't let Dr. X touch you. Would you allow a mechanic to work on your car after telling you he could not identify the problem but he wants to go ahead and take the top of the engine off anyway.

Regardless of his skill as a surgeon, it is just bad business to treat a patient that way. You should call him on the fact that you were able to view the CD and understand the interpretation and notes entered by the radiologist.

Anonymous said...

Paul,

Did any MD see your friend during his first hospital visit? Why he was not screened for foriegn body during his first visit with imaging?
BTW..what is your take on mid-level providers (PAs/NPs/CRNAs)playing the role of docs in Health Care Industry?

Star Lawrence said...

I didn't like the sound of "stitching up without taking out foreign debris" to begin with. You need a hand surgeon. They tend to be pretty uppity, even for surgeons. This guy sounds like you are not wavelengthed. I would not let him operate. Yes, when getting into these medical jackpots, we must take a leap of faith at some point, but I don't like the sound of this person.

Tashumi said...

Paul,
first,as said in earlier blogs, the nurses or on duty doctors should have checked before putting stiches.Then they wonder about rise in the medical lawsuits.
Second,the material minded medical professionals may not be concerned, as they are going to get their consulting fees through insurance anyways.Better avoid this one for the future.
Third,refer to first, if proper care would have been taken to clean the wound, then probably May 2nd surgery could have been avoided.

Anonymous said...

It's standard care to do an exploration and wash-out of any laceration before stitching it up, and anyone can do that after having been taught how (I did it as a medical student, and an advanced-practice nurse is probably better than your average MS III.) Shards of clear glass 1 mm or less could easily be missed, though, and your friend should have been instructed to return for follow-up if he had any further symptoms, which it appears he did. (There is no anatomical explanation for the pain along the length of his arm, but the wound site pain could be caused either by the glass splinters, the stitches, or the laceration itself.)
Two questions: how does he KNOW there was no exploration done? (It may not be obvious if you don't know what you're looking for.) And---is he SURE it was a nurse who stitched him up and not a female physician/PA? (After 24 years of introducing myself as "Dr." at least a quarter or more of my hospital patients still refer to me as a nurse---I give up.) If it really was a nurse stitching him up unsupervised, she is breaking the law by practicing medicine without a license. . .

Anonymous said...

If this happened the way the patient describes it (and I only say that because laymen may misunderstand certain things, not that he is deliberately exaggerating or anything else), it is pretty egregious in several respects. First, the first nurse should have ruled out nerve or tendon damage right away. Second, depending on the circumstance (was the glass jar filled with something?), the nurse needed to determine if it was a dirty or clean wound, which determines stitching or not stitching and the possibility of antibiotics. Third, the doctor sounds incompetent or a first class jerk or both.
I suggest the patient write several formal complaints - one to the certifying board of plastic surgery and one to whatever hospital at which the surgeon proposed operating. Then one to the supervising physician at this college - was this a student health center or what?
I don't know the official name of the plastic surgery Board but he can google it (or ask Paul to ask his plastic surgeons). This should not go unaddressed.
Being married to a hand surgeon and given probable nerve damage, I second the suggestion to see one.

Anonymous said...

This story sounds familiar. Many years ago my daughter cut her finger by forcibly jamming a pipette in chem class. Pediatrician saw it, cleaned it and bandaged it. When I mentioned the subsequent loss of feeling in the finger to a vascular surgeon (at BI), he insisted my daughter needed to be seen by a hand surgeon. I had to argue with the pediatrician for the referral. He said even if the nerve was damaged, it would to difficicult to repair. An RN in the office helped me get the referral. My daughter was seen by a surgeon at the BI, he felt that the nerve was only partially damaged and would not require surgery. As an afterthought, he sent her for an xray. Only a few minutes after having the xray, he called me, lo and behold there was glass in the finger, resting on a tendon. He was very surprised at this finding. He removed it surgically, although tiny particles remain which could not be removed without incurring more damage.
I respect the pediatrician, but will always fight for a second opinion.

Toni Brayer MD said...

I agree with all of the previous posts and a first year med resident learns that debridement and "copius" irrigation is needed prior to sutures being placed. You do need a hand specialist and you should not return to the "out by 1:00" physician. It is critical that a patient have confidence in his surgeon. Find a good hand surgeon and good luck to you and all of your digits!

rjh said...

Ted,

It is common to ask for a CD for DICOM transfers between organizations. It avoids the massive headaches associated with connecting networks, as well as all the associated costs. It also immensely simplifies the HIPAA issues. As the patient, you have the right to get your records and give them to anyone you want. Patients don't have to maintain extensive documentation on their own data disclosures. So patient delivered CD's avoid all kinds of administrative bother.

If it is a time critical activity, the network connections are worth the effort. For a non-critical referral like this, the CD is much less expensive for all involved.

Mary Lu said...

Paul,

The situation of this physician not seeing the glass on the xray is nothing new.

Several years ago my mother in law fell and the ER physicians were concerned about her hip being broken, but when the xrays showed it wasn't, they couldn't understand why she was still pain. For giggles and grins my husband a Director of Pharmacy) and I (a lowly hospital admin' looked over the films on the boards and within 1 minute I pointed to the 1/2 inch gap in her pelvis. I pointed it out to the Doc's and said... "Ah, could "this" be her problem?" The MD's face turned about 14 shades of red... Yes! But how did you learn to read xrays? I just smiled and told him, my old college sweetie is a radiologist now and we were #1 & #2 in our A&P Class. Reading xrays is a hobby of mine.

Mary Lu

Anonymous said...

Did the surgeon put the CD in the computer? That's about the only explanation I can think of for failing to see an annotated diagram.

Anonymous said...

This reminds me of the dentist I went to who told me during one visit that I had a cavity. Six months later when I went back to see him for my usual cleaning he told I had no cavities. I said oh the cavity I had six months ago must have went away on it's own.

eeka said...

Yeah, it's too bad s/he didn't know enough to demand that the ER do it correctly -- and too bad s/he has to.

I cut my wrist slicing a bagel last year and went to the ER. It was a really deep cut with a lot of blood loss and loss of sensation, but my hand basically moved correctly. The ER was about to just stitch it up, but then asked whether hand function is important to my occupation. I'm a music therapist, so yes, being able to play instruments is essential. So they sent me to surgery, where they did scans to make sure no knife shards were in there, and then poked around and found that I'd hacked up the artery and the tendon and damaged a bunch of nerves. A hand surgeon repaired all this.

But shouldn't they have done this regardless of my occupation? Your friend should have also had the same care. There's no reason to do a halfass job repairing anyone's injury when it's possible to repair it correctly.

Anonymous said...

I sustained a similar injury (to my wrist rather than hand). The doc on call at the ER ordered an x ray. Can someone tell me how large a piece of glass needs to be for it to be seen on an x ray?