How often have you, as a clinician, either been told a dud bit of information - or conveyed one- when discussing a clinical case? We probably all have. It's the equivalent of idle chit chat, which in gossip can cause emotional and other harm, but in clinical care it could kill. Such misinformation has almost certainly lead to doing unnecessary operations, tests etc
I had a patient who kept getting put on theatre lists for 'wound excision and exploration'. He had been labelled as a case of pyoderma gangrenosum for years, by various doctors, including dermatologists. This 'clinical meme' had stuck to him. He quoted it himself. He certainly had intermittent cutaneous sepsis, but PG is a very specific condition, the treatment for which includes immunosuppression, which no-one had quite got round to. It all seemed very unlikely to me. It certainly wasn't a classical presentation.
So I got the old notes - they were pretty thick. The meme had been repeated on many occasions, but never proven. No histology, no test of treatment, yet here he was continually turning up and getting listed for surgery for possible deep infections, with this impressive label stuck to him. The notes told a long and confusing but very helpful story, if you took an hour to read them.
I sent him back to see a new, very thorough dermatologist. No evidence of PG. It turned out to be self-inflicted, AKA dermatitis artefacta. A completely different sort of problem.
Likewise, if you do a lot of revisions (I do), you will encounter plenty of patients who have undergone multiple surgeries - occasionally into double figures - with different implants, approaches, rationales etc. There is no more useful exercise in planning treatment than summarising the relevant old notes and imaging - often going back years - and sending a copy to the GP. Clarity is everything here. It can be extraordinarily revealing. It's one reason why when I first meet a patient with a problem joint replacement one of my first questions is: why was this done, did they ever have painful arthritis in the first place? That may sound daft, but it is incredible how frequently the answer to their dissatisfaction lies in a poor original decision to operate.
So back to our wise surgeon, Leo Gordon. The Four F's are a bit outdated, and there's a mention of something called the World Wide Web, but this is the voice of experience. Get the old notes!
No comments:
Post a Comment