CodeBlueBlog: 50 Ways To Lose Your Testicle

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50 Ways To Lose Your Testicle

50 Ways To Lose Your Testicle

An almost indecipherable blurb that should not have made it out of the newsroom has Danny Curtis, of California, filing a lawsuit to address injuries incurred when a surgeon removed one of his testicles that was predicted to harbor cancer, but did not:

A man is suing an area hospital and one of its surgeons, claiming one of his testicles was wrongly removed during surgery.

Danny Curtis claims Dr. Albert McBride, a surgeon at Kern Medical Center, did not conduct a biopsy before arranging urgent surgery to remove a testicular tumor in July 2004, according to the lawsuit filed in Kern County Superior Court.

Doctors later discovered that the tumor was not malignant and did not need to be removed, according to court documents.

We really cannot say much about such a complex case given the exiguous amount of data revealed by the story, but two medical blogs made a valiant effort. Kevin, M.D. and The Doctor Is In do a good job of outlining the appropriate medical data concerning the diagnosis and treatment for suspected testicular cancer. Take home lesson? In short, one does not first biopsy intratesticular masses. Given the evidence, presurgical biopsy is associated with worse outcomes, so one must go straight to surgery once the lesion is detected. Case closed.

It's Easy to Lose a Testicle...or Kidney...or

Which brings me to MY two cents on this issue. People are shocked when they learn that Danny Curtis lost a perfectly good testicle in this seemingly unacceptable way. But it isn't at all bizarre to me. In fact, there are a lot of ways you can lose your testicle in this situation.

Analogously, there are a lot of ways you can lose your gall bladder, your ovary, your lung, and your kidney. It's easy.

In my opinion, the urological surgeon has little culpability in Danny's case, as long as standard procedure was followed. Because the urological surgeon does not make the diagnosis of an intratesticular mass, the radiologist does. And this is the complex issue that may finally be at the nub of the aforementioned lawsuit. And it also leads us to explain how it's easy to lose body parts when you don't understand what is going on, how it is going on and how it can go wrong. Easy.

Twenty Questions

How much do you think that Danny Curtis knows about testicular ultrasound? Does he know that an ultrasound probably sealed the fate of his testicle? How many patients out there, who need or have an ultrasound, can answer the following questions:

What is an ultrasound test?

What kind of machine is used during an ultrasound test?

Who actually performs the examination on your body? What is that person's training and expertise? Is it regulated?

What happens to (or with) the images generated by the ultrasound machine?

Who LOOKS at the images? Is it usually the doctor who SENT you for the exam?

Do you think that the doctor who scheduled the examination could capably interpret the images?

Can ANY doctor interpret ultrasound images?

Who is the best person to interpret an ultrasound and what is his or her training and certification?

Most people cannot answer these questions. Why not? If I asked you similar questions about your home air conditioning unit, I think you would do well. And there's not even a gonad at risk!

Periscope Up

Ultrasound is a derivative of sonar, the technology used to locate, track, and characterize things underwater. To interpret an ultrasound, one looks at an indirect image that is a reconstruction of reflected sound waves. Just think of all those submarine movies with a sweaty sailor poring over the blips that might represent a sperm whale...or a nuclear-tipped torpedo.

It's analogous to medical ultrasound -- in more ways than one. The ultrasound machine uses sound waves to locate, track, and characterize THINGS inside your body. And there's a sweaty radiologist at the other end trying to figure out if the amorphous blip is a simple lesion...or a deadly cancer.

Testicular ultrasound needs to be done by an experienced technologist and interpreted by an experienced radiologist. Notice I said interpreted. Because that's what one does with an ultrasound: interpret the image. Even in the best of situations, some testicular tumors are difficult to see or PERCEIVE.

The Answer Is NOT Printed On The Film

Here's an US:

Sorry for the small image, but you get the picture. Radiologists are gazing at little collections of echoes and trying to decide if the pattern is normal or abnormal or even cancer -- in which case the testicle needs to be removed -- without a biopsy.

A testicular tumor, on ultrasound, appears as an area of slightly decreased echoes -- in an area of many echoes. The diagnosis is one of degrees. One observes an area that does not seem to be as echogenic as a neighboring area. If one can reliably document this phenomenon in two different axes of the testicle (like longitudinal and transverse), then a presumptive diagnosis is made.

THE WAYS:

So if you get a testicular ultrasound, and you don't know which questions to ask and what the right answers are, then you are gambling that all the stars are aligned that day, because there are fifty ways to lose your testicle.

What are some of them?

WHOSE GOT THEIR EYES ON YOUR NADS?

Testicular ultrasound needs to be interpreted by someone who has learned how to read the images. Sounds logical, right? Formal training takes place almost exclusively in radiology residencies.

Then again, even radiology residents sometimes don't get enough training in testicular ultrasound, and it may take a radiologist a few years to really get good at the task.

So, if the person interpreting your ultrasound did NOT train as a radiologist or does NOT have experience interpreting the exam, he or she may look at a normal echo-variation and interpret it as a cancer ---------------> LOSE TESTICLE

"I'M NOT SURE IF THIS IS ABNORMAL" ... ERR ON THE SIDE OF...

Sometimes the answer simply is not clear-cut. There is an area that looks a little abnormal, but is it really? Maybe. Maybe not. Should the interpreter err on the side of over calling or under calling subtle abnormalities? Almost always, one will over call ---------------> LOSE TESTICLE

DON'T TOUCH THAT DIAL!

The technologist who is performing the ultrasound has to gage the background "echo level" needed to study each body part. This is done with manual adjustment of the gain. If the technologist sets the gain too high, a cyst (benign) can look like a solid mass (cancer) ------------------> LOSE TESTICLE

FAT IN ALL THE WRONG PLACES

It is difficult to get clear images in an obese patient. The sound beams have to traverse the layers of fat, and in doing so they get "lost." This causes degradation of the images (formed by the sound bouncing off the testicle and making it back to the machine). The echo drop-out can lead to "holes" in the scan. These can be misinterpreted as lesions ------------------> LOSE TESTICLE

I HAVE THIS ITCH

Likewise, a patient can have a rash or an incision or some other skin condition prohibiting good contact (this is essential for ultrasound exams) of the ultrasound machine with the scrotal skin. Less skin contact means fewer good echoes sent and received and again, echo drop-out can lead to "holes" in the scan. These can be misinterpreted as lesions ------------------> LOSE TESTICLE

DOC IN THE BOX = GONAD IN THE BOX

The "clinic" you go to for your ultrasound is owned by a schizophrenic zoophagous hermit who lives in -- and directs the clinic from -- Antarctica. He operates the facility only for profit. To maximize his return he buys second hand, dilapidated ultrasound machines on the world-wide medical imaging equipment black market. He hires inexperienced technologists, and radiologists who are on the lam. Because the machine generates bad images with "echo-holes", the technologist doesn't understand what he is doing, and the radiologist is still sobering up, a normal contour change is called a tumor -------------> LOSE TESTICLE

Bottom line? A lot of things can go wrong. There are a lot of ways you can lose your testicle. And you'd never know what hit you.

You see, there are issues in quality control that you've never dreamed of and you have no inkling exist, and this is unlike any other service area or product in the free market system. Because ultrasound of the testicles does not exist in the free market arena. So these little MAJOR items and issues of quality assurance and control are the ghosts in these machines, acting in innumerable ways unknown to the consumer, because the consumer doesn't care... because the consumer is so frozen out of the decision to choose and understand quality in medicine that even a testicle cannot be called safe.

Experience, equipment, expertise, and acts of God. There are fifty ways to lose a testicle, but you can whittle them down to one: acts of God.

But you gotta learn. Get educated. Choose. Be free.

DON'T LEAVE IT UP TO GOD. TAKE CONTROL OF YOUR MEDICAL CARE NOW.

Posted by Doctor CBB on March 02, 2005 at 09:45 AM | Permalink

Comments

Interestingly, an anecdotal case from Sweden has shown there could possibly maybe be a chance of a potential(note the qualifiers) protein biomarker for testicular cancer:
http://story.news.yahoo.com/news?tmpl=story&cid=571&ncid=751&e=3&u=/nm/20050303/hl_nm/health_cancer_dc

If this works, it could possibly maybe be a chance it could potentially someday allow for earlier screening and detection of this condition. This could allow for a second round of screening and detection to confirm a although if the cancer is present the testicle still gets removed.

Posted by: Saint Nate | March 03, 2005 at 09:17 AM

Remarkably good, frank post. But, you should be an expert witness for plaintiff's trial attorneys. Obviously, the medical profession cannot discipline itself. After all, doctors always say, "Trust us--we give you the best possible care." However, as you point out, so often they don't.

I'm so relieved that the tort system exists to deter some of these myriad errors!! Thank you, Dr. CodeBlue & thank you trial lawyers!!!!

Posted by: | March 07, 2005 at 03:55 PM

Spare it, because it's lost on me...anyone who follows anything that I write here knows how I feel on this issue.

There is malpractice in many forms. Who denies that? There are good and bad doctors. Honest and dishonest. they come in all forms.

I believe intensely that bad medicine needs to be addressed.

Why is it NOT addressed? How does it CONTINUE?

Because the tort system is the dumbest, most venal, most illegitimate way to find and remediate malpractice because it is motivated by what torters can earn and most of the cases are settled outsoide of court, hushed up and signed off.

CONSUMERS can address malpractice by becoming informed.

Torters help not a lick.

Posted by: CodeBlueBlogMD | March 16, 2005 at 09:44 AM

Dr. Blue,

That's absurd. Can consumers make intelligent decisions about healthcare? No--and the reason is doctors themselves. Can consumers get statistics and metrics on doctor performance? No. Can consumers get statistics and metrics on hospital infection rates? No. Can consumers get information on suits settled against doctors? Generally, no. Can consumers get data on the number of procedures doctors do per year? Many times not.

Until consumers have this info, true markets can't work. (Remember most economic models ASSUME PERFECT INFORMATION). So be it venal, corrupt, blah, blah blah, the tort system is probably the best consumers can do to keep doctors honest. Without info., the market can't.

Posted by: | March 17, 2005 at 12:42 AM

Yes, and until penicillin, amputation was the best surgeons could do to halt the spread of infection.

I agree with all your "cans," but the only absurdidy here is your claim that information is sequestered by doctors themselves.

The free market you pay lip service to, as imagined by Adam Smith, is a place where many people of variable ability ply their trade. The free market assumes that many of these same people will be self-interested, and some will be dishonest. However, the system accounts for all players by the mechanisms of choice and feedback.

The reason that the free market system does NOT exist in medicine has nothing to do with physicians, as all informed students of the history of United States health care know.

It was the initiation of third party payment systems, begun in the 1940's, compounded by the government's entry into healthcare (Medicare/Medicaid) in the 1960's that took consumer choice and outcome feedback out of the equation.

I've said it before and I'll say it again. Open up the system. Let me advertise my abilities and charge what the market will bear. Make consumers reponsible -- in some form -- for their health care costs and they WILL learn, they WILL get informed, they WILL judge outcomes -- and a thousand industries will sprout up to assist them.

Until then, I guess you are right. We just all have to accept missing arms and legs because the only system we have now to find malpractice -- designed and maintained in a Matrix-like fashion by tort lawyers -- is set up not to find bad doctors but to blackmail insurance companies for the enrichment of unconscionable scallawags.

Posted by: CodeBlueBlogMD | March 17, 2005 at 10:24 AM

Wow--we're close to agreement. And, you're absolutely right, there won't be anything approaching rationality in allocation of medical resources until American kick the addiction to third-party payers.

Still, I'd like you to see how in a true free market, you'd still need med mal--tho most people probably would trade their rights to sue in exchange for cheaper service. But, that may be a bridge too far. . .

One last point, you know that we'd also have to get rid of licensure. But I have no problems with that. Instead of telling people I have an MD after my name, I'm wonderful--doctors would have to demonstrate their skills (i.e., performance metrics verified by third parties) Is that a bridge too far for you, Doctor?

Posted by: | March 17, 2005 at 07:05 PM

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health care also health·care (hlthkâr) n. :efforts made to maintain or restore health especially by trained and licensed professionals -- usually hyphenated when used attributively

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	Webster's Online Dictionary The Rosetta Edition™
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