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« Kennedy Speaks and We Remember: A Voice To Ignore; An Ignored Voice | Main | CSI MEDBLOGS: DOES BILL CLINTON HAVE AIDS OR CANCER? »

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Listed below are links to weblogs that reference CSI MEDBLOGS: WHAT'S REALLY WRONG WITH BILL CLINTON NOW? :

» Catching my eye: morning A through Z (afternoon edition) from The Glittering Eye
What with getting the Carnival of the Liberated up on Dean's World first thing in the morning, Tuesdays sometimes just get ahead of me. Here's what's caught my eye so far: There doesn't seem to be a lot of commentary... [Read More]

» Catching my eye: morning A through Z (afternoon edition) from The Glittering Eye
What with getting the Carnival of the Liberated up on Dean's World first thing in the morning, Tuesdays sometimes just get ahead of me. Here's what's caught my eye so far: There doesn't seem to be a lot of commentary... [Read More]

» Cry Wolf Blitzer from blogborygmi
CodeBlueBlog's CSI: Medblogs tackles the Clinton Effusion and asks some probing questions. [Read More]

Comments

C.S.

This seems like a sort of a cynical take on the situation. True, your deduction that something else may causing the effusion seem sound, however your suggestions of what else might be causing it all seem like the worst case scenario.

I developed a bacterial pneumonia (as a teenager) which was none too severe, in the sense that the bacteria was pervious to virtually all common antibiotic options for pneumonia. And yet, I still developed a pleural effusion and had surgery during which the VATS procedure was ineffective and they had to spread my ribs and open me up. Even so it's an example of a dangerous but still less than terribly life threatening situation that resulted in a major pleural effusion.

CodeBlueBlogMD

Well, the list of items that cause exudative effusions is large, but finite. Bacterial pneumonia is one of them but I did not include that because it was never reported that Clinton HAD pneumonia.

I have a new post on this case.

To me it is extremely unlikely that Clinton would suddenly develop a complicated (exudative) effusion FIVE MONTHS after his surgery.

I think there is something REALLY bad wrong here.

alwin

When the left internal thoracic artery is taken during CABG, the left pleura is left open. When patients (and surgeons) are in a hurry to d/c the chest tube, you get a higher incidence of left pleural problems, IMHO. I think this is a case of a "Celebrity Complication", caused by pressure to take shortcuts and make things look good for the media.

I don't think the scenario of a clotted hemothorax that has progressed to a loculated area is as unlikely as you suppose, and a famous Top Knife has supported the idea of an open procedure to definitively diagnose and treat the problem.

Have to agree with him; my experience is that procedures like this are best done with direct visualization.

CodeBlueBlogMD

Then you are saying that he's had the pleural problem SINCE his surgery.

So how come they only found it a month ago?

Did it take five months to accumulate?
Has he had NO follow-up chest X-rays?

And if it DID develop ONE month ago, is it likely to be secondary to the surgery?

I agree that they are doing an open procedure for a definitive diagnosis, but a diagnosis of what??

Did they aspirate and get cytology? What did it show?

If it was YOUR effusion, would you just agree to a VATS that is likely to be coverted to a thoracotomy, or would you ask the thoracic surgeon to put a chest tube in there, try to break up the loculations first?

Top Knife or no, I'm a top Eye. Does anyone thing there should be a work-up? You don't want to do a PET scan to look for malignancy or a bronch to evaluate that collapsed lung? The literature suggests that you should.

alwin

Yeah, I guess I am saying that he has had problems since surgery. As for only finding it a month ago, I'd guess that he finally admitted to having problems and had it checked - my experience with hard-chargers is that they minimize symptoms and make excuses, both to themselves and their care-givers, as to why they don't feel 100%.

Celebrities often demand - and get - different treatment than the standard protocol, despite there being very good reasons for those rules being put in place. I wonder if perhaps he didn't get "fast-tracked" at his request, in spite of the need for another day or two of his chest tubes being left in place. There are a number of reasons I could think of for it being done, from pain control to a wish to "return to health".

My preference, were I in his place, would be for open thoracotomy and visualize the problem, then make a decision based on what s/he sees. No VOMIT (Victim Of Medical Imaging Technology) for me - open me up, look around, act on what s/he sees.

CodeBlueBloigMD

I just erased a nasty reply to your stupid VOMIT crack.

Suffice it to say that I am frequently bemused at what a surgeon insists he saw through a keyhole incision versus what I'm telling him exists on the panoramic three dimensional photographs of the same area.

But then again, I am held accountable by the images -- THEY DON'T LIE. A surgeon doesn't take pictures so it's almost impossible to challenge what he said he saw.

I wonder what your connection to medicine is?

I know no sane, experienced physician who would welcome an open thoracotomy (and the million little things that can and do go wrong) if there were any other reasonable options.

Insofar as Clinton, what you are saying is that he had no chest X-rays and NO AUSCULTATIONS of his chest after he left the hospital, because either of those exams done competently would have revealed an abnormality that required follow-up.

Finally, it is my opinion that the BEST physicians reach out with their imaginations in their diagnoses.

I don't chase zebras, but I alwyas 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.

Good luck to you.

Nick

Hello CBB -- I replied your four (!) comments on my blog earlier today. As usual, you approach things very logically, very thoroughly, and I had to do a bit of reading before preparing a response. It's always a pleasure to to try to match wits.

A big chunk of your inquiry arises from the "one month" timeframe, which you heard on NPR but I can't find transcripted. I did find a report that Clinton noted dyspnea on exertion a month ago, but I think it's possible that his doctors were aware of an effusion earlier. Maybe they saw it post-op and figured it would resolve (as most do)? Maybe Clinton cancelled followup visits until symptoms appeared, and by then, the effusion had walled off? Maybe it's large or sclerosed enough to deter efforts by chest tube, or maybe Clinton declined that option in favor of likely definitive therapy?

It's a lot of maybes, but to me seems more plausible than a malignancy, and explains the curiously lax workup.

cardioNP

A surgeon auscultate the chest? You've got to be kidding. Have you not heard the joke that surgeons put the head of the 'scope at about the xiphoid process and that hits all three areas of assessment - heart, lung, abdomen?
I was at my mother's bedside for 2 weeks following her CABG (she fell and broke her patella, had chest pain which led to her cardiac work-up and subsequent CABG - so her post op course was very atypical). Since nursing care generally is inadequate in most facilities due to understaffing and high patient acuity, I essentially spent 8-10 hrs a day at the hospital - otherwise there would have been no one to help transfer my mother from bed to chair or the bathroom (she had to wait 2 weeks post CABG prior to patella repair).
Not once during their rounds did I ever see a surgeon auscultate my mother's lungs. When I realized she was still 02 dependent 2 weeks following surgery (desatted on room air), I went and got my own stethescope and identified decreased BS and rales. She had severe atelectasis and a raised R hemi-diagphragm. Thankfully her patella repair was postponed until aggressive pulmonary toilet was done and her oxygenation had improved.

Jim Hu

Did you mean mycoplasma or mycobacteria? The latter is TB, the former is walking pneumonia (and frequent contamination of tissue culture cells)

Jackie

What about Mesothelioma?

CodeBlueBlogMD

cardioNP:
Hope you are doing well.
I understand exactly what you are saying.

However, this IS a former president and he is likely to be Craig Smith's most famous patient forever. So...jeez...you'd think he would have done assiduous follow-up.

But it isn't really Smith, it's Clinton's internist and his private physician. I mean, good Lord, Clinton must have had an abnormal CXR and asymmetrical breath sounds for months! And given that these effusion, although rare 6 months after surgery are COMMON one month after surgery -- how did they miss it? I posted on this today...

JIM--------> no, I meant mycobacteria. Mycoplasma would present like a pneumonia (or bad cough) whereas certain Mycobacteria (like aviuum) can be tricky and sneaky.

JACKIE------> malignant mesothelioma is in the differential diagnosis of pleural disease/malignancy, certainly.

Jim Hu

I thought you meant Mycobacteria, but you wrote "Strange infections such as: Mycoplasma (TB)..."

alwin

Sorry if you think VOMIT is stupid - I think it's a real syndrome, shrugged off by imaging specialists when a patient is opened up and no/different pathology is found.

And now the follow up - Clinton gets an open procedure because you can't do peels that big with a 'scope. Upshot, he gets four hours of a general anesthetic instead of the two an open chest procedure would have run, along with a number of extra holes in his chest.

But what the hell do I know? I'm just a friggin' nurse - and not for very much longer, at that.

codeblueblogMD

Jim---> oops...thanks, you are correct; I meant Mycobacteria

Alwin---> That makes sense, all of it.

ddb

My observation is not exactly medical.
In the election, Teresa Heinz Kerry, keeled over at
a private home in Kansas I believe making a little lecture.
The very next day Mr. Clinton is suddenly rushed
to the hospital with a "4-vessel bypass".
I now begin thinking hmmm hospital/good secure place.
No prying eyes. What is going on?
Because when I watched Teresa Kerry in the video
she says something is not right, and she grabs her head.....the next day it's reported she has a stomach problem. Never in my life have I grabbed my head to say I had a problem with my stomach.

Now I start remembering the guy with the messed up face over in Europe during
all this time that somebody tried to assisinate through
his food.

And recently, here we have Hillary Clinton, passing out on the podium also. She got right back up, but again red flags went up for me.

No, Clinton doesn't look good. But I would bet you money it isn't his heart.

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