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SOME MEDICAL
CASES
- Bili-lights...at home:
After an uneventful 3rd pregnancy, a 25 y/o
white female had labor and delivery induced at 41 weeks (a week past her due date),
productive of an 8 lb, 11 oz girl with excellent Apgar score of 9/9. Cord-blood bilirubin
level was significantly elevated at 12; cord blood type was B+ and mother was
O+....."ABO-incompatible hemolytic disease of the newborn", a usually mild problem, was
diagnosed. Baby was placed under bili-light to aid in reducing the elevation. 48 hours
after birth, on Friday, an apparently well baby and mother were discharged home, a baby's
blood sample drawn for the discharge base-line record. Totally unexpectedly, the blood
count showed the platelets (tiny blood components which prevent bleeding) to be only 50%
of normal levels....a potential sign of potentially fatal bacterial sepsis (blood
poisoning); the blood WBC absolute neutrophile count was never higher than 7000. A family
member pathologist reviewed the blood smear as well as having previously processed the
baby's placenta (after birth) to be sure all was normal. The on-call pediatrician was
able to quickly check the baby to be sure the spleen was not enlarged, to be sure the
baby didn't seem toxic, to repeat the lab tests (which duplicated the earlier values),
and to receive assurance from the pathologist that the blood smear did not look septic
and that the placenta was definitely negative for ANY evidence of a hidden infection.
Antibiotic treatment was with-held, and the baby was allowed to return home Friday
afternoon and was monitored without any treatment... all values returning toward normal
by Monday. 10% of placentas from apparently normal deliveries like this have evidence of
a hidden infection....usually not making itself known or being a problem. What if your
newborn turns sick in the 1st 48 hours...wouldn't you like for the doctors to know what
the placenta has to
tell?
- Thank
goodness our lab processed the Pap smear, too:
We received a hysterectomy specimen on a 40 y/o female with a history of "abnormal Paps". Our
routine gross (with the naked eye) exam was negative for anything unusual; so, routine slices
of the uterus and cervix were taken for microscopic exam. When our pathologist viewed the
slides the next day, they were all perfectly normal. And the abnormal history was initially
unexplained. But the most recent Pap smear had been diagnosed in our lab due to the fact that
the physician office was now owned by our hospital; and our hospital policy was that all
surgical and cytology (anatomic pathology) specimens were to be "tested" by the fully
credentialed, fully-in-compliance with State Board of Medical Examiners (state licensing Board)
pathology group members based at the Lexington Med. Ctr. hospital. The pathologist reviewed the
abnormal Pap slides and determined that a significant, as-yet-unexplained abnormality was
present. As a consequence of the fact that these pathology services were being done at
"the point of service," the
discordance between the history and the uterus findings became obvious and compelling. The
pathologist returned to the uterus specimen container and re-examined the specimen...once
more it appeared unremarkable to the naked eye. Our pathologist, predicting the likely site
of abnormality, sliced in all of that area of the uterus for microscopic exam. The next day,
the slides came out and showed a small and dangerous cancer. The pathologist contacted the
gynecologist who noted that the patient, years ago, had a series of abnormal Pap smears
which were followed for several years by "normal" Paps in a commercial lab. Immediately upon
getting the abnormal diagnosis on the most recent Pap, the patient was called in and was
resistant to a strong (because of the recurrence of Pap abnormalities) recommendation for
hysterectomy. Fortunately, the gynecologist prevailed; and the hysterectomy was performed.
Fortunately, the doctors office, hospital, and pathology group were in a system of "point of
service pathology". Fortunately, the gynecologist and pathologist were "good
doctors"...citizens actively participating in, living in, and devoted to their local
communities. They went the extra mile. They did what was right (not what might have been
viewed by medical businesses as cost effective). And the patient received the subsequent
"icing on the cake" of the additional therapeutic measure of radiation therapy. She is
cured!!! Outside of a smoothly functioning "point of service" pathology coverage, she might
not have even been diagnosed! Guess what...had a disastrous false negative diagnosis (missed
diagnosis) occurred, it would have not made even a "blip" in so-called quality assurance
monitors of the Wall Street type medical business world.
- The right hand
didn't know what the left hand was doing:
A 63 y/o man, father of a long-time official in a
local hospital obtained his usual care from his family doctor on the other side of a
metropolitan city. At one point, that doctor ordered a CT scan of the man's abdomen at a
down-town, commercial image center whose reports did not reside in any of the hospital computer
information systems. He developed back pain and was seen at another area...the largest
(medical-school associated)...hospital. Studies showed bone "lesions", one being of the breast
bone. A biopsy was done and the lesion was simply diagnosed as a "metastatic malignant tumor".
He was referred for radiation therapy at the local hospital of his child. In order to better
plan therapy, the radiation oncologist needed information about the tumor (the above was a
"cost-effective", minimalist diagnosis). It was shocking to the local pathologist at the
radiation therapist's hospital to see that no more had been determined. The story had been
obtained "by word of mouth" (since the report was not available in the information system) that
CT scans looking for an original (primary) tumor were negative. Slides were borrowed (taking
almost a week). It was seen that special stains would be needed from an expert pathology group
on the opposite side of the USA. More slides had to be requested and then forwarded to the
distant group. The studies highly suggested that the tumor came from the patient's liver. The
radiation oncologist, a "good
doctor", investigated much harder and was able to track down the studies at the commercial
imaging center. In fact, the CT studies had been highly abnormal, demonstrating cirrhosis of
the liver and ascites...a setting risky for the growth of a primary liver cancer. A blood test
was positive and added confirmatory evidence. Now the case made sense and proper radiation
treatment was executed.
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TRUTH
(case #1 posted 3 Aug. 1998; #2 posted 17 Aug.
1999; #3 posted 17 Aug. 1999.)
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