Never Offer To Cut Off Your Own Leg

At least, not in the Army.  They might just take you up on your offer.

Joe (do I really have to tell you that this isn’t even close to the guy’s real name?) had problems with his left leg after 2 deployments to Iraq and multiple exposures to high-velocity trauma.  Lots of problems, shall we say.  The leg often doesn’t work much at all.  Sometimes, this overwhelming feeling of burning pain spreads from his mid shin up to his knee and then pulses up into his thigh for hours.

But what’s debilitating leg pain got to do with being in the Army?  At least, that’s how Joe sees it.  Unlike most soldiers in the WTU, Joe is determined to stay in the military.  He wants to be sent “down range” (deployed) again.  Tomorrow, if possible.  He loves his unit and enjoys the excitement of his job. 

Joe does not understand that a soldier who can’t walk probably isn’t going to do well in a war zone.

Actually, Joe is quite smart.  He understands perfectly well that a debilitated soldier can’t perform a required in a combat situation.  But he doesn’t care.  He loves the Army.  Lives for the Army.  So he has worked with a lawyer for over a year now to keep himself in the Army.  The WTU doc before me has worked to this end – admittedly with some bemusement – for the past few months as well.

Recently, Joe met with a special review board comprised of high-ranking commanders.  They evaluated his chart, looked over the reports of his injuries, and then interviewed him personally.  I think this occurred at Walter Reed Hospital, in Washington D.C. in – the Mecca of Army Medicine.  As you might imagine, this was a big deal.

I don’t know the exact specifics of that interview, but here’s my reenactment:

“Soldier, you’ve served your country well.  We thank you for your sacrifice and heroism.  After thorough review of your file, we have determined that you are no longer qualified for active duty and will therefore be separated from the military with full medical coverage and benefits.  You will be given an honorable discharge and should have no problems entering civilian life.”

“Sir, it’s the leg, right?  That’s the problem?” Says Joe.

“Correct, Sargent.”

“What if the leg wasn’t a problem?  What then, sir?”

“Why, you’d stay in the military, Son!  Send you down range week after next.  Get you back in the fiiigght, boy!”

“Then cut it off!  Just cut the damn thing off!  I can run on a prosthetic.  There’s less to clean up if I get crosswise of an IED (roadside bomb) again, right?  Just send me down there with a couple of extra legs in my pack and I’m all good.”

This – honest to God – is a relatively faithful reenactment of this soldier’s conversation with his Army superiors.  Admiring his courage and commitment, I was more surprised to find that, following this meeting, our doctors in the WTU received this order from on high:

****de, de, d, d, deeeee —Official communication from High Command:  SGT Joe to be referred to surgery for evaluation of chronic leg dysfunction and pain.  Consider surgical correction.  Amputation a viable option.——-de, d, d, deeee,

***** Stop.

Gestational Diabetes – What We Did

A while ago I wrote a ‘You Be The Doc’ regarding a patient with borderline gestational diabetes. That patient had her baby recently, and it was something of a white-knuckle affair. Here’s what happened:

The initial test for GDM is a 1 hour glucose tolerance test, and the patient was VERY positive with a score in the 190′s. In the medical world, it’s considered bad form to designate someone as ‘very’ positive, or ‘borderline’ positive. These numbers are cut-offs. If you are past the cut-off, you’re positive. That’s it. No rounding, no data massage. The cut-off for GDM is 140. So the test is positive.

There are lots of reasons why the 1-hour GTT is lame. You can eat virtually anything on the McDonald’s menu, then come to the clinic and take the test and have a pumped up test result. So, because you can’t really trust a 1-hour GTT, we follow it with a similar test that is at least a bit more rigorous (still lame, though). The 3-hr takes 4 blood glucose tests – a fasting, then 1, 2 and 3 hours after drinking a sugar-rich solution. Our patient had normal values for all but the 4th test, and it was only off by about 3 points. 3 points! Everything else was normal. In my last post, I pondered whether or not to bestow the diagnosis of GDM on this patient with this glucose profile.

We did not. We told her she was fine. No intervention.

Hey, we’re family doctors. We’re mellow. A coupla out of range values. So what? No big deal right? Actually, you might ask, what is the big deal? Well, the whole point is to determine if your body can metabolize (that is, put away) glucose correctly. Glucose – sugar – in your blood stream is a BAD thing. It doesn’t belong there, it belongs in your body’s cells. Think of it as energy. Like little burning, flaming, sparking packets of sun-beam radiation (that, incidentally, also taste really, really good). As this stuff flies around your blood stream, it’s like an average 2 year old boy left alone in a glass-blower’s museum (well, at least my 2 year old boy). This is, metabolically speaking, why eating high-sugar foods isn’t healthy…or at least risky. At any point, your body may look at all that glucose tearing apart your capillaries in your eyes and kidneys and brain, start wringing its metaphorical hands and just curl up into an useless whimpering pancreatic fetal ball and give up. If, for some reason, your body can’t vanquish the insane levels of glucose the average American pours into their arteries in a given meal, you have diabetes. High blood glucose levels cause all kinds of problems. The most important of which, in pregnancy, is HUGE kids. We call ‘em “macrosomic”.

My patient – who we did not treat for GDM – went into labor around 8pm. Very little cervical change occurred through the first 10 hours. By noon the next day – we’re talking about 16 hours of labor here – she was finally ready to push. After pushing for 5 hours, the baby still wasn’t out, in fact, she hadn’t really moved at all. Imagine, after five hours of the hardest work you’ve ever done in your life…you get to hear your doctor say something oblique and vaguely encouraging like, “You’re doing GREAT! I’m sure things will progress if we keep working.” There’s a thing called the “labor curve” to mention here. Typically, if there isn’t continual cervical change, and steady descent of the baby once the patient starts pushing, the patient is said to be “falling off the labor curve.” When this happens, docs need to start looking for a problem. In general we look for one of 3 P’s: Power – mom just can’t push hard enough or uterine contractions not strong enough, Pelvis – is the “chute” too small?, and Passenger – is the kid too big? In this case, the patient was off the curve, and we couldn’t be sure that any of the P’s were adequate.

We were able to see the baby’s head well enough to allow us to use a vacuum, which did help bring the baby into the base of the pelvis. At that point, we had an OB in the room to evaluate for C-section. She was particularly concerned with our decision to not treat for GDM based on this patient’s glucose profile. Almost certainly, she said, this baby was macrosomic because she, by definition, had GDM (remember, our 4th value was out of range by 3). She also said that she would have treated the patient for GDM based on her very high 1-hour test, forgoing the 3 hr. entirely, since it had been “very” positive.

You can imagine my handwringing concern at this point. I let this patient sit around for MONTHS, cooking up a huge baby that was not going to get stuck in her pelvis. Bad things happen when babies can’t fit through pelvises. To think I could have prevented it by just being more aggressive early gave me the opportunity to experience some new emotion – as yet unnamed – that combines stark fear with wistful, sharp regret and a sticky sort of guilt all mashed together with insecurity and self-castigation. We’ll call this feeling FRGIS. Mid way through this experience, I felt extremely “Frgis-y”. That is, quite terrible. I’d, perhaps singlehandedly, resigned this mother to surgery (best case), or perhaps something more terrible due to shoulders, head or neck getting stuck in the birth canal.

In the end, the vacuum (which only adds about 10% more power than the uterus and mother already provide) created just enough extra oomph to get the baby’s head through. The shoulders were a tight squeeze, but there was no distocia (shoulders caught on the pubic bone…can be REAL bad). The mother hemorrhaged and required 3 different medications to get it stopped, and she had a pretty good-sized laceration that took about a hour to repair. But the baby did fine. Actually, rather cute. I usually think they look like aliens.

The upshot was that the baby weighed around 8 lbs. This IS NOT MACROSOMIA! This is a big baby, but not medically large. In the end, we had nothing more than a difficult delivery, which probably had more to do with the mother being new at pushing and not really knowing how to do it than anything else. More stringent glucose management may have helped keep the baby a bit smaller, but she wasn’t especially large even without management. And the patient got no shots, no medications and no extra worry about having a metabolic disease while she worried about just getting through her pregnancy.

In the end, the patient ended up with a beautiful, normal-sized baby. Yes, there was a pretty big laceration, but these are relatively common irrespective of the size of the baby. But in general, our management was within the standard of care, although there is room to debate whether or not we should have been more aggressive. True, the doctors lost hair and years from their lives (or, my life, anyway), and experienced the wonderful emotion called FRGIS, but hey, this is medicine, right?

Missed Diagnosis

So, I finally did it. I correctly diagnosed a previously-missed diagnosis. I’ve found that most of the time when a doc talks about catching something all the other super-smart docs missed, they have some sort of ax to grind. Most commonly – and not to start a war about the merits of chiropractic – I’ve heard it from chiropractors. I even heard one talk about how he correctly diagnosed herpes zoster after the patient had seen two other specialists.

Sometimes, like with the chiro guy, I don’t believe the stories. Mostly, though, I don’t believe in myself enough to think that I could catch something these other incredibly smart docs miss. I remember my med school class. Those people were SHARP. I watched them evaluate and diagnose patients every day. It never seemed like they missed a THING while I was always bumbling around trying to untangle myself from the IV tubing. Now, in residency, I’m a little less in touch with my colleagues, but they all seem so infallibly competent as well. I trust most of them implicitly. This is doubly true of the docs who are working and practicing in the community. These are full-fledged doctors. How could I ever do it better than them?

But I did. It wasn’t because I was smarter or better. The diagnosis was simple. If anything, I picked up what others missed just by listening to the story. Maybe everyone else was rushed when they saw this patient. They all got into highly competitive residencies and ostensibly know more medicine than me. But somehow, four doctors mis-diagnosed this patient. I knew his problem within 10 minutes.

The patient is a middle-aged male who came in saying he had an appointment with a specialist (a urologist) because he’s been having severe pelvic pain for the past 2 weeks. Come to think of it, it’s actually been much longer than that, but the past 2 weeks it’s been really bad. He was seen by two doctors in an urgent care clinic, who first gave him antibiotics and told him he had an infected prostate (in spite of a perfectly normal UA), and then gave him pain meds and told him to go to the ER if things got worse. Then he went to our vaunted ER, and was also told he had prostatitis and maybe prostate cancer and that he needed to see a specialist.

Sitting my office, he says he “hates doctors” (greaat, nice to meet you too) and hasn’t seen one since he was 12. He’s one of those tougher-than wood kinda guys that has worked in construction since the trade was invented. And I notice that he’s near tears. It’s the cancer bit, I figure. Works every time. I don’t know why docs throw that out there when they have no evidence. So now this guy is sitting on the exam table, visibly shaking, taking deep breaths and scared to death. I’m thinking that it would be easier to make a slab of drywall cry than to make a guy like this emotional, so I know he’s about a low at he gets.

None of his symptoms sound like prostatitis. Or a UTI, which is pretty rare in males anyway. The pain argues against cancer. Few people this upset are mere drug-seekers, and he isn’t asking for drugs anyway (although seekers use this tack frequently too). “Let me see this famed abdomen,” I say. I already have an idea that he simply has hernias. Sure enough, one quick check and it’s abundantly clear he has bilateral, indirect inguinal hernias. A med student coulda made that diagnosis. I think HE thought it was hernias. But both he and I figured we must be wrong because all these brilliant, well-trained docs said it was something else.

“Nobody’s actually done that exam thing on me,” He said as I took off my glove. “They always just jammed a finger up my butt. Don’t you need to do that too? I HATE the finger thing.”

“I hate that test too” I said (just read my blog about it, I think sardonically) “But I’d do it if I thought you needed it…and you don’t. You have hernias and if you go see that urologist, whatever doc referred you there is going to be pretty embarrassed. Cancel the appointment. Today. You don’t have cancer, either. It’s a simple surgical problem; you’ll be out of the hospital the same day.”

He couldn’t believe it. “REALLY?” He says. We look at each other in perfect understanding. I’m not offended by his suspicion. I’m this punk family medicine resident, not even out of training yet. I ride a skateboard to work, my hair’s never combed and I’m rarely on time. I went to school in Israel as a ploy to make global traveling look legitimate. Who am I to contradict wiser heads than mine?

“Man, I’m telling you. I’m dead-on. It’s hernias.” It felt good, strong, to say that. Even if it was only hernias.

Yesterday, I saw the guy again. Surgery is done. He’s all wide-eyed and looking at me like I’m brilliant. Says he told everyone in the ER (went back there while waiting for surgery because the pain got so bad, and got the surgery emergently that night) that I was the only doc in town who got the diagnosis right. I’m sure the ER doc loved hearing THAT. In truth, I made an elementary diagnosis partly because other stuff had been ruled out and partly because I had the time and wherewithal to really listen to the guy’s story. I think that’s why there’s more than one doc on this planet, and why there’s such a thing as second opinions. None of us gets it right every time, which is why I hate medical litigation. We’re all just human. I don’t even want to THINK about how many times my colleagues have picked up the fragmented pieces of my near-misses and forged them into a good outcome for my patients. But, for once, it was gratifying to be the guy who picked up the pieces. To make things right. This patient thinks I’m a hero. I figure it was just my turn…and it sure was fun.

You Be The Doc – Gestational Diabetes

One of the more difficult things to deal with in medicine – I think – is borderline lab values. A huge component of most medical decisions relies on the patient’s latest labs; often the decision is almost perfunctory. But what about times when lab values are just barely positive? For example, a normal blood pressure is 120/80. What if a guy has 122/80? Is that hypertension? Should I put this disease on his problem list…there for insurance companies to see and thus charge him more for life or health coverage?

Most lab values can be manipulated to some degree. The entire field of biofeedback starts from this premise. In biofeedback models, the lab values can be changed by effectively willing your body to change it’s own parameters. If effect, you can think yourself to a lower blood pressure, lower cholesterol, more hair…maybe even bigger sexual organs I suppose. Go for it. Imagine big, big gonads if you want. See what happens.

Anyway, some people consider this mere quackery – I think it will be considered a fad in a few years – but some swear by it. And yeah, I’m sure there is some bridge across the Cartesian mind-body quagmire we’ve been wallowing in since Modernism awoke, but I’m not sure biofeedback is that bridge. Aside from whatever volitional input we may have on our bodies, there is the fact that all lab tests have margins of error associated with them. You hear about “sampling” error in all these perpetual polls in the presidential primaries. Obama leads Clinton 47 to 42 percent…but the margin of error is plus or minus 8 points. So Obama doesn’t lead anybody. He and Clinton are tied. Many of the good polling companies actually do some real statistics to come up with these numbers, but it doesn’t really matter much because none of us voters really care. All we care about is who’s gonna win the stupid thing? Who’s the prez gonna be? And, (for me) WHO’S FINALLY GOING TO PUT AN END TO DYNASTIC, BOURGEOIS RULE IN AMERICA?

Sorry, this is a blog, so I can digress and feel only a little bad. The points are that lab values are manipulatable both physiologically and statistically. The statistical manipulation – the margin of error, for example – exists because determining something like the amount of glucose molecules in a sample of blood isn’t exactly easy. There’s 2 major ways to do it, and a 3rd less-popular way as well. Each way is different from each other, so if you determine glucose values using Type 1, and then use Type 2, you have to convert one to the other’s value to even determine if they’re equivalent. The conversion is a math equation, not observational science.

Why does an average doc like me care about all these details? Well, these facts play out in my mind when I get a lab value that is juuuussst barely out of range. A positive value means the patient has a new disease that can affect their ability to get health insurance (a quaint little reality of this American health system I admire so much), but also can affect their care. One little lab value can determine if a person suddenly needs to take expensive medicines – brand-name cholesterol-lowering meds are a couple hundred bucks a month, for example. Or it may mean that they now qualify for surgical exploration to find a possible tumor. Some people have had things cut off of them – like breasts – only to find that they didn’t have cancer at all. This is called the false-positive rate and is one of the biggest reasons why I try very hard NOT to do even little tests on patients unless it really looks like they need it. Breast self-exams are a classic example of dangerous false-positive tests that lead to sometimes catastrophic interventions occasionally for no reason. **Disclaimer on this one: major controversy exists about whether or not breast self-exam are good or bad. This was just an example. Keep doin’ em if you do ‘em.**

When pregnant, one of the things we screen for is gestational diabetes (we call it GDM). This disease only shows up during pregnancy, and often vaporizes just after the baby is born. It more resembles Type 2 DM than Type 1 in that it won’t really kill you in the short-term, but deranged glucose values give the patient headaches and lots of nausea and makes them feel pretty much miserable. The problem is that high glucose in the mom can lead to huge problems with the baby. First of them being that the baby can be, in fact, HUGE. But they can also end up obese in life. They usually end up with REAL diabetes. Being so big, there are risks for the delivery that aren’t pretty too.

So, we need to avoid GDM. We screen for it by giving the mother an oral glucose test at 28 weeks. She drinks this sugary solution – absolutely disgusting…I’ve tried it – and then testing her blood sugar levels an hour later. This is a classic screening test: It has lots of false-positives, but fewer false-negatives. It’s reasonably good for catching GDM. But because of the fasle-negatives, we do a second test to try to filter some of them out, which is basically the same test with more sugar solution and blood tests every hour for 3 hours. People who have out of range glucose values for both tests, probably have GDM and need treatment which can include testing glucose values 3-5 times a day (rather painful, a bit bloody, and not cheap). The might also get insulin shots, based on the glucose values. They are usually sent for nutrition counseling to teach them how to eat basically no-carb foods. They also get regular ultrasounds every month or less to determine if the baby is getting too big, which may lead to C-section. And while we’re on the topic of false-positives, ultrasound becomes less and less accurate for determining weight as the pregnancy progresses. By the end of the 3rd trimester, the US could be off by as much as 2 lbs! An alarming US can easily lead to surgery when in fact the baby is of normal weight.

So, my patient had a 1-hour glucose test of 199. The cut-off is 150. That’s obviously positive – she qualified for the 3-hour test easily. The first test of the 3hr is a fasting glucose test (arguably the most important) and she was well under the limit. Her second test, at one hour, was also well below the threshold for GDM. Third test – at 2 hours – also negative. Then, at 3 hours, her test was 164. The cut-off was 160. She has a positive value. She may very well have GDM.

You be the doc. What would you do?

Here’s some possibilities:

A.) Bring her back for another 3h test, since they can be falsely positive (and, actually falsely negative). In other words, they aren’t always accurate.

B.) Give her the full-monty: regular US, daily glucose monitoring, insulin, diet counseling, weekly visits, evaluation for c-section

C.) One or two elements of option B – a partial intervention, so to speak

D.) Tell her the test is “fine” and leave it at that. Effectively, regard the test as negative, and tell her this.

E.) Bring her in and just test her glucose twice a week. Treat her if one of those values is out of range.

**I’ll describe what I did in a week or so.**