Am I Conspirational or Observant?
I've taken a lot of heat for making observations and asking questions. Isn't this what people want from the Blogosphere? Kevin M.D. does a much better job analyzing the news and staying current; Chris Rangel has a keener eye and more passion for the policy issues; Dr. Charles and The Madhouse Madman (congrats bud) explore the literary and humanistic aspects of their jobs. None of that is what I do here. I look at the nonsense that passes for medical news and ask questions whenever that news does not make sense to me, which is just about always.
What really is offensive is when I ask questions and OTHERS say I am claiming cover-up or conspiracy. I am doing neither of those things. Nothing I say cannot be traced along a logical thought-line with documentation both in the literature and by my extensive training and experience. That's part of what I offer. Let me also say here, publicly, what I wrote to one of my commentators, previously.
... it is my opinion that the BEST physicians reach out with their imaginations in their diagnoses.
I don't chase zebras*, but I always wait for them. And I've caught a herd of them in the last 20 years-- because I'm not afraid to question someone's established order of case presentation and history.
I still get thank-you cards and letters from patients who were zebras when I found them in some physician's barn of horses. In medicine there is a saying: you can't find something if you don't know what you are looking for. It sounds trite, but it holds a lot of import. Just because I ask COULD this unusual circumstance have an unusual diagnosis doesn't mean I am going to kidnap Bill Clinton and treat him with chemotherapy but if you don't think about those possibilities, you will never make those diagnoses.
--- NOW LET ME TELL YOU WHY I AM RIGHT ABOUT THIS CASE--
The Most Dangerous Game
Yesterday, the physicians at Columbia Presbyterian admitted that one of my three possible scenarios was indeed, correct. They missed his complicated pleural effusion for five months.
either they failed to do appropriate follow-up and MISSED it for six months (unlikely); or, they have been hiding his problem while they exhaust all nonsurgical treatment options; OR ... Bill Clinton's exudative pleural effusion is from something else.
Yesterday, as reported in The Times, they physicians at Columbia made several points:
#1. Clinton's pleural abnormality was undetected until one month ago
#2. It is their contention that this abnormality has been present since the bypass surgery and is a direct complication of that surgery
#3. The presence of a chronic complicated loculated pleural collection after bypass surgery causing pleural thickening, inelasticity, and lung collapse (traction atelectasis) is very rare. How rare? REALLY rare. Said Dr. Craig Smith, Clinton's surgeon:
This is a very rare complication
(I've seen it) only a handful of times in 6,000 surgeries.
So, some of the best doctors in the world did a procedure (bilateral mammary artery harvests) that has a high risk of post operative occurrence of complicated effusions, then missed that effusion when it occurred (in their most famous patient ever), then failed to follow up that patient until he came back to them with chest pain and shortness of breath.
The panel of Presbyterian physicians made a major point of insisting that a persistent complicated pleural effusion causing pleural fibrosis and lung collapse is a rare complication -- and indeed it is.
HOWEVER, what they didn't say was that if they had detected the relatively commonly occurring complicated effusion immediately post-op then maybe this rare sequelae could have been avoided. This rare complication is actually probably the natural history of an undetected, untreated,complicated postoperative effusion.
So, cut the BS guys.
Here's how rare the effusions are according to the Archives of Internal Medicine:
All patients underwent internal mammary artery grafting. Early effusions (<30 days after CABG) occurred in 45 patients (63%) and late effusions (30 days after CABG) developed in 26 (37%).
So, his doctors knew that Clinton had a really good chance of developing an effusion with this procedure. So how did they miss it??
Rara Avis: We Try Harder
Most of the letters I've received have made the point that Clinton was likely noncompliant; however, given the frequency of complicated pleural effusions after bypass with the mammary arteries, the docs should have been hard on the case.
Surely Bill Clinton has had a chest X-ray abnormality for MONTHS; and surely he has had unequal basilar breath sounds for a similar period of time.
Did Clinton not EVER see an internist after his bypass? Does the former president NOT have a personal physician? Did that personal physician NOT listen to Bill's lungs? Would he not have noticed a DRAMATIC asymmetry in breath sounds between the right an dd left lower lobes?
I WAS RIGHT TO BE SKEPTICAL
Because I gave the benefit of the doubt to the surgeons and physicians taking care of Clinton, I almost completely dismissed the possibility that they would have MISSED this relatively common sequela of mammary artery harvesting.
I therefore had to question whether or not there was some other reason for a complicated pleural effusion, and any doctor worth his mojo would immediately think of cancer. Period.
I tell you what. I'm still skeptical that they actually missed this bad problem and I wouldn't be at all surprised if, later today, they tell us that Bill Clinton's pleura is SOCKED IN with tumor.
Let me say something else. EVERYONE is downplaying the severity of this procedure (thoracocoscopy / thoracotomy). Hilliary Clinton, displaying naivete and lack of any medical insight at all said yesterday:
"It is a routine procedure although it is an uncommon complication,"
Since when is a thoracotomy routine? I mean what is the definition of routine? Clinton is undergoing general anesthesia for a VATS with likely conversion to a thoracotomy (you know, widen the incision, spread the ribs and violate the thorax?). They will be performing a therapeutic pneumothorax with the risk of persistent pneumothorax, bronchopleural fistula, infection, stroke...I could go on ... Here's one reference to decortication:
Postoperative complications included 8.7% wound infections and 1.2% recurring empyema. Operative mortality was 1.2%. The indication for decortication to improve pulmonary function alone is questionable. As a rule it is based upon 2 factors--both elimination of infectious foci and improving function.
So stop foisting this on us as routine. A rectal exam is routine. This is major surgery.
Good luck to you Bill. I hope I am wrong. And I wish you well.
*There is a maxim in medicine that says: when you hear hoofbeats, think horses not zebras. The idea is that common things are common and a goodphysician should not be confabulatng wild explanations for situations that probably have a routine cause.
However, GOOD physicians understand that the statistical distribution of diagnostic possibilities fall under a probabilistic curve that includes many rare and unusual entities. Thus, although one should not CHASE zebras, it is my cntention that neither will a good physicians fail to CATCH a zebra should one run by.