Over to you
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Right level, wrong site (1)
I read the September 2011 Casebook with interest, specifically the report on “Right level, wrong site” (p21). I know of more than one surgeon who believes that all lumbar disc lesions can be approached surgically from the midline!
That is unequivocally untrue as your expert so rightly pointed out. One of my points comes from your section on learning points in relation to the management of acute lumbar disc lesions. In the lumbar spine the spontaneous resolution rate for acute disc protrusions is closer to 100% than 80%, but specifically time-related.
Sadly the world literature is badly biased by the fact that surgeons tend to advocate surgery and it is not in their interest to be promoting conservative management: a cynical but truthful observation. Patients should be advised that the outcome of conservative versus operative treatment is little if no different at 12 to 18 months. Surgery offers the advantage of a short cut but risks not insignificant complications; conservative management has minimal risk but often a drawn-out recovery. Extraordinarily I have read notes that record that patients with lumbar disc lesions will not get better without surgery!
In relation to the time allowed for spontaneous resolution of these lumbar disc lesions, four to six weeks is, I have to say, an exceptionally short period of time to suggest before considering surgery. Certainly there will be occasions, short of cauda equina compression, where in special circumstances early surgery may be considered – but the message that MPS supports such early surgery may not be a good one to be promulgating.
Surgeons tend to advocate surgery and it is not in their interest to be promoting conservative management: a cynical but truthful observation
I know that the difference between private and public treatment standards in respect of surgical advice exists and I am pleased that you raised that, to try to keep practitioners honest in that respect.
Another interesting point arises in relation to communication. Doctors (surgeons) can be quite foolish on occasions by telling patients that a particular treatment previously given to their patient was wrong simply because it was not their own practice. This is particularly important now that the ‘school of opinion’ defence has been challenged. Doctors should be taught and reminded that they must resist the temptation to portray themselves as the saviour of a situation by denigrating previous unsuccessful but perfectly proper treatment.
As an orthopaedic spinal who performed more than 7,000 open spinal operations, I do speak from a depth of experience. One final point in the form of a question. Are surgical trainees and newly-appointed consultant surgeons being formally and appropriately (not voluntarily) appraised of their responsibilities in relation to medical insurance? It would be difficult if not impossible to argue against mandatory malpractice education as a requirement for medical insurance!
Name and address supplied
Right level, wrong site (2)
REF “Right level, wrong site” (Casebook 19(3), p21). An interesting case with possible implications wider than the ones you mentioned. Was there a governance structure in place in this doctor’s organisation that reviewed his previous operations to see if he had inappropriately operated on other patients? Do doctors in MPS have an obligation to inform the Medical Council about the possible concerns about this doctor?
Paul Scott, GP, UK
I should reiterate the comment we make in “On the case”, that reports are based on issues arising in MPS cases from around the world, but facts are altered to preserve confidentiality. To that extent the reports are not factual iterations of individual cases. The issue you raise is one MPS takes seriously and during the course of every case we seek to work with the member to identify any risk management issues that could bear on future practice.
Mother knows best (1)
I read with great interest the case “Mother knows best” in the last issue of Casebook, 19(3). Whilst we continually strive for excellence and perfection, it is impossible for doctors to make accurate diagnoses on every occasion. The difficulty is highlighted in this case where the initial presentation of intermittent twitching without any other symptoms is rather atypical for bacterial meningitis. This can be easily missed.
Therefore, the learning points in the article are absolutely valid and correctly emphasised. Parent concerns should always be considered and a high index of suspicion is required to avoid misdiagnosis. More importantly, it is imperative that junior doctors on-call should always discuss the working diagnosis with a senior colleague in spite of how confident he/she feels or how cumbersome this may seem. Occasionally, patients may re-present 24-48 hours following the first presentation to hospital with worsening or persisting symptoms. It is vital that the patient is seen by a middle grade doctor or above at this stage.
Parent concerns should always be considered and a high index of suspicion is required to avoid misdiagnosis
Had this been applied to the baby in the above-mentioned case, the outcome might have been very different. I believe that the learning points from the article apply to all junior doctors regardless of their specialty rotations. Not least will this exercise be life saving, it could also potentially save a budding career.
Billy LK Wong, junior doctor, UK
Avoiding dosing disasters
David Mitchell's professor is correct (Over to You, Casebook 19(3)). Drug charts should be reviewed on all patients at every ward round, and ideally every day. This ensures that prescriptions have not been made overnight that clash with those drugs already prescribed, that initial prescriptions are reviewed regularly and that drugs no longer needed are stopped. I work in critical care and it is our practice to review the drug chart daily, looking for issues before it is reviewed again by the critical care consultant on the ward round.
I strongly agree that focusing solely on the initial prescriber is wrong
Drugs are stopped, doses altered in light of altered renal function and other drugs started if they have been omitted or forgotten. Every day we check if thromboprophylaxis has been prescribed or considered contraindicated, if gastroprophylaxis has been instituted and that appropriate nutrition and anti-pneumonia measures are in place. Analgesics, sedatives, inotropes and vasopressors are reviewed, and antibiotics and steroids stopped if they have run their course.
I strongly agree that focusing solely on the initial prescriber is wrong. The inpatient care of a patient is the responsibility of all of us involved in their care. We should all be reviewing drug charts regularly to minimise prescription errors.
Chris Smith, specialty registrar, Anaesthesia, UK
Mother knows best (2)
I reminisce to my Foundation Year 2 days in the emergency department. I found dealing with children and particularly neonates to be the most challenging part of my medical career so far. From this stems the utmost respect and admiration for all qualified and aspiring paediatricians.
To get back to the subject matter, I do remember taking two lessons away from my brief period spent in the department. The first one relates to history. We are indocrinated from our earliest days in medical school that over three quarters of the information you need to make a diagnosis or at least decide on the next course of action is in the history. In the case of the young ones still lacking language skills, we can only rely on the mother’s history, even when this is sometimes limited to a story.
I always felt that a mother’s concern was enough to take things forward, especially if a little reassurance was not adequate. There is no substitute for a mother’s sixth sense of something being amiss. None other than she would be able to discern the smallest changes and nuances in the behaviour and hence the overall condition of her baby, and this is proof enough of her worry. There is no way that you could confidently fully discern normality in the short period of contact you have with the child in the department.
We are indocrinated from our earliest days in medical school that over three quarters of the information you need to make a diagnosis or at least decide on the next course of action is in the history
The second lesson is if there is a reattendance within the last 24 hours; an expert consult needs to be sought, even if it is to reassure all parties concerned of the benign nature of the presentation. The worst thing that could happen with getting a second opinion is another medical professional doing what he was trained and is paid to do: his job!
With these two skills in hand, it should not be too difficult to navigate the delicate waters of the paediatric department in accident and emergency.
Ali Abdool, registrar in cardiology, UK