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Thou Shall Not Pass

Thou Shall Not Pass

Every morning when I arrive at the office, the ritual begins. I am greeted by Tammy sitting at her desk facing the side entrance of the office, I put my personal items in my office, walk to the break room for one half of a cup of coffee, then I stand at the nurse's station to go over both the game plan for the day and field any questions about patient care issues that were pending from either the day before or the night that just passed.

Some issues take time to resolve. That takes us back to one of my blogs several weeks ago. Tammy asked me if I had finished the referral of our fourteen year-old wheel-chair bound quadriplegic patient who was suffering from a variant of Gillain-Barre' syndrome to a private infusion facility for IVIG treatment. To refresh your memory, she was admitted in mid-August to LeBohneur Hospital for evaluation and treatment of acute onset quadriplegia. The parents and patient have been so understanding in this situation, almost Zen-like in their approach to the emotional and spiritual challenges that face them during her recovery.

The pediatricians associated with LeBohneur hospital are seen in television commercials in the Memphis TV market as kind, compassionate experts in their fields of medicine. They are represented as dedicated professionals to their practice. In addition, one gets the impression that the nursing staff and administrative staff shares their physicians' drive and motivation to get to the bottom of any illness, no matter what the cost to the institution both economically and emotionally. The truth is that LeBohneur as an institution is like every other institution in America: all marketing, no substance.

In order to refer my patient to an infusion center for IVIG treatment, I had to write a history and physical that accurately reflected the care and treatment provided by the experts at LeBohneur. The family brought me what they considered a complete copy her medical records of her hospital stay. I read them from beginning to end. I was not surprised at the inconsistencies of her care and the lack of communication that the family endured between the physicians and the patient in this case.

First off, there was a LeBohneur-based pediatric hospitalist overseeing the care of my patient. She was young, inexperienced in taking care of ill children and absolutely closed minded about our patient's diagnosis. I had spoken to her on the phone once or twice, but she had no intention of considering any else's clinical opinion about the case. I asked her to consider IVIG therapy. She remarked that the neurologist on the case refuses to entertain the diagnosis of Gillain-Barre' syndrome; he diagnosed Conversion Reaction and the Hospitalist was going to honor his position over anyone else's. She could find no reason not to give it, but refused to order it because the lead neurologist refused to agree to its administration. The Hospitalist had no professional opinion about her diagnosis, she thought the case was over-her-head and simply parroted the neurologist who believed our patient to be neurologically normal. The family's recollection of their discussions with the Hospitalist were not remotely similar to what was written in the medical record. The notes reflected quite the opposite.

They consultants ordered only a limited amount of blood work. However, the studies showed undetectable levels of thiamine in her blood. Thiamine deficiency causes three distinct forms of neurological disease, one of which is a painful polyneuritis and loss of motor function. There is no mention of the thiamine deficiency in the physician notes, however they gave her thiamine intravenously and her pain symptoms in her extremities started to resolve.  They performed EMG's on her upper and lower limbs which were inconclusive of Gillain-Barre' Syndrome; the neurologist who read the examination remarked that the tests should be repeated in two weeks since it may have been too early in the disease process for the nerve conduction studies to be abnormal.  

She had an MRI of her spine with contrast, the results of which was normal. The consultants remarked that the MRI was performed to avoid the trauma of a lumbar puncture, the only true test that is considered the gold standard for diagnosing Gillain-Barre' syndrome.

She had a number of consultants evaluate her in the hospital. The lead neurologist on her case had notes showing his physical examination revealed active reflexes in all of her extremities and no clonus. Another neurologist on the case found no reflexes in her upper and lower extremities except for hyper reflexia in her knee reflexes. She found clonus also. According to the patient, the lead neurologist hit her with a heavy large hammer multiple times in multiple extremities, only to get frustrated over and over again because he could not illicit a reflex. The Neurologist concluded she had reflexes even though they were absent, wrote his factitious findings in the chart and maintained she was just having a conversion reaction. He also took her hand, put it over her face and dropped on her face. The neurologist recorded in the notes that the patient guarded her face, the family said they told him to stop doing the test since she kept hitting her face with her hand. I believe the family. Her parents and the patient being examined both bedside said that the patient did not move a bit after each strike of the hammer and she did not guard her face with each hand strike.

The lead neurologist denied the presence of clonus in her feet (an abnormal sign which cannot be faked with conversion reaction). The emergency physician who admitted the patient, found hyper-reflexia in her knee reflexes and otherwise loss of all of her other deep tendon reflexes on his neurologic exam. Her found no guarding of her face with hand drop. The emergency physician admitted her to the intensive care unit because he was concerned she might stop breathing in her weakened state. Clearly her physical exam was confusing, since the only physician who could find reflexes and face guarding was the lead pediatric neurologist.

The Infectious Disease specialist on the case dictated a long convoluted consultation, citing that our patient had unexplained elevated Mycoplasma Pneumoniae IgG and IgM titers, but came to the conclusion the test results were unreliable. She had comments about me in her note, stating that her conversations with another Infectious Disease specialist in town revealed that I was a fringe physician in Memphis who relies on clinical laboratory data from unreliable niche laboratories located in California. She named the physician she spoke with in her note; I do not know that physician personally or professionally nor do I employ the services of fringe clinical laboratories in California. The comments were out-of-place related to the patient's illness and disturbing to anyone reading the medical record. The final thought from the infectious disease specialist was that our patient was suffering from a neuro-endocrine tumor of some sort and it had to be found before it was too late. Between you and me, the ID doctor drank the Kool-Aid a long time ago. That's like concluding that a webbed footed, feather covered animal that swims in the water and quacks is a Zebra. I hope she's not the best LeBohneur has to offer our children. We as a community are sadly underserved by these ignorant professionals who cannot admit when they are lost caring for a sick patient.

The psychiatrist who evaluated our patient for conversion reaction had no conclusion one way or another. His medical consultation read like an essay from a high school student's final examination topic: describe a Conversion reaction as it relates to stress and human disease. The psychiatrist could not find any evidence of Conversion on his mental and emotional examination but he hinted that he had not seen a case of Conversion in a child or adolescent who did not have some source of horrific trauma. She had none.

One last note about the medical record. Only one ICU nurse claimed she saw our patient move voluntarily. She stated in her notes that the patient moved in her sleep. On questioning the patient and her mother, her mother stated that she moved her to keep her from getting pressure sores. Each time the nurse would come in her room and find her in a different position, she concluded that the patient moved herself. The nurse did not ask the patient's mother if she moved her. This is poor medical care and very poor charting on behalf of the nurse caring for the patient.

It took hours to read the chart and compose something meaningful from the medical records during her fourteen day stay in LeBohneur for the infusion center. There were countless contradictions in the chart which implies no one was in charge of her case, everyone had an opinion and most unfortunate, none of the doctors were able to see the obvious diagnosis because their egos and world views blinded them from the truth of her disease. Have I seen this type of Tomfoolery in medicine before? Yes. Far too often!

I hope the infusion center will administer IVIG to her to reduce her recovery time from her autoimmune disease. Furthermore, I hope the country wakes up one day to see the corruption that is alive and well in the practice of medicine. Not the kind of corruption that takes your money and leaves you broke; it's the kind of corruption that takes your trust in allegedly experts in their medical field and leaves you dead or disabled for the rest of your life. Not because you did anything wrong other than to suggest you have a disease or illness that you would like them to evaluate and they took your unsolicited advice as criticism and built a case for something you did not have to avoid giving you the satisfaction that you were right about your illness.

In my experience, physicians in our community and others can and will withhold life changing treatment as punishment for your unintentional step across their line in the sand. Thank goodness this adolescent child is progressing in a positive way since not all Gillain-Barre' patients recovery from the disease without any of their prescriptions or advice. They had none.

And the line in the sand? Thou shall not pass!

Doc 

Posted by Amanda Sanders at 11:34 AM
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